Provider Demographics
NPI:1689859829
Name:MIRO, SANTIAGO (BS, MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:
Last Name:MIRO
Suffix:
Gender:M
Credentials:BS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0880
Mailing Address - Country:US
Mailing Address - Phone:866-482-5419
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:540-536-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2351732085R0202X, 2085R0204X
PAMD4350002085R0204X, 2085R0202X
WV278872085R0204X
VA01012545282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1689859829Medicaid
VA1689859829Medicaid
MD982902400Medicaid
VT49887OtherBLUESHIELD
VTOVN2555Medicaid