Provider Demographics
NPI:1902823867
Name:SANTILLAN, EDGAR R (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:R
Last Name:SANTILLAN
Suffix:
Gender:M
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:PO BOX 771861
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-1861
Mailing Address - Country:US
Mailing Address - Phone:937-556-4324
Mailing Address - Fax:937-350-6477
Practice Address - Street 1:2400 MIAMI VALLEY DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-556-4324
Practice Address - Fax:937-439-3786
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.075548208M00000X, 208M00000X
OH35-075548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2489016Medicaid
OHH08980Medicare UPIN
OH2489016Medicaid
OHP01524401Medicare PIN
OHH187281Medicare PIN