Provider Demographics
NPI:1942483003
Name:SANTANA, IDA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:LOUISE
Last Name:SANTANA
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 1:584 BROADWAY
Mailing Address - Street 2:SUITE 510
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3229
Mailing Address - Country:US
Mailing Address - Phone:202-827-6646
Mailing Address - Fax:202-827-6646
Practice Address - Street 1:584 BROADWAY
Practice Address - Street 2:SUITE 510
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3229
Practice Address - Country:US
Practice Address - Phone:202-827-6646
Practice Address - Fax:202-827-6646
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231523207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY231523-1OtherNY MEDICAL LICENSE