Provider Demographics
NPI:1558843623
Name:SANTIAGO, TEDDY
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101B SOUTH WASINGTON
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301
Mailing Address - Country:US
Mailing Address - Phone:660-851-0537
Mailing Address - Fax:660-460-7417
Practice Address - Street 1:101B SOUTH WASINGTON
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301
Practice Address - Country:US
Practice Address - Phone:660-851-0537
Practice Address - Fax:660-460-7417
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty