Provider Demographics
NPI:1558367920
Name:ESCOBAR, SANTIAGO (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:
Last Name:ESCOBAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4203
Mailing Address - Country:US
Mailing Address - Phone:203-333-4044
Mailing Address - Fax:203-330-0761
Practice Address - Street 1:2837 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4203
Practice Address - Country:US
Practice Address - Phone:203-333-4044
Practice Address - Fax:203-330-0761
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB83705Medicare UPIN