Provider Demographics
NPI:1801847462
Name:SANTIAGO, MARIVIC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E RIDGEWOOD AVENUE
Mailing Address - Street 2:SUITE 480N
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652
Mailing Address - Country:US
Mailing Address - Phone:201-447-8151
Mailing Address - Fax:201-447-8526
Practice Address - Street 1:140 E RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE 480N
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-447-8151
Practice Address - Fax:201-447-8526
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA067651002080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics