Provider Demographics
NPI:1710099585
Name:CENTURION, SANTIAGO ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:ALBERTO
Last Name:CENTURION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:106 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2356
Mailing Address - Country:US
Mailing Address - Phone:707-763-6816
Mailing Address - Fax:707-763-1730
Practice Address - Street 1:106 LYNCH CREEK WAY
Practice Address - Street 2:SUITE 8
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2356
Practice Address - Country:US
Practice Address - Phone:707-763-6816
Practice Address - Fax:707-763-1730
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA07649600207N00000X, 207ND0900X, 207ND0101X
CAA866380207N00000X, 207ND0900X, 207ND0101X
NY231911-1207N00000X, 207ND0900X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI07968Medicare UPIN
NJ077955Medicare PIN
CA00A866380Medicare PIN
NY9RR322T081Medicare PIN