Provider Demographics
NPI:1942312103
Name:COLON-SANTIAGO, MARIBEL (MD)
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:
Last Name:COLON-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 1:2112 NW 55TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3118
Mailing Address - Country:US
Mailing Address - Phone:580-248-0972
Mailing Address - Fax:580-248-0972
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5270
Practice Address - Fax:580-354-5289
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10773174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR83073OtherMEDICARE PROVIDER NUMBER
PR83073OtherMEDICARE PROVIDER NUMBER
OKF98679Medicare UPIN
OK8HZ54RMedicare Oscar/Certification