Provider Demographics
NPI:1629389572
Name:IVETTE SANTIAGO M D P A
Entity Type:Organization
Organization Name:IVETTE SANTIAGO M D P A
Other - Org Name:CENTRAL FLORIDA HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-385-0123
Mailing Address - Street 1:17521 US HIGHWAY 441 STE 15
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6737
Mailing Address - Country:US
Mailing Address - Phone:352-385-0123
Mailing Address - Fax:352-383-3533
Practice Address - Street 1:17521 US HIGHWAY 441 STE 15
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6737
Practice Address - Country:US
Practice Address - Phone:352-385-0123
Practice Address - Fax:352-383-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1316966708OtherINDIVIDUAL PROVIDER NPI
FL1316966708OtherINDIVIDUAL PROVIDER NPI