Provider Demographics
NPI:1104131077
Name:SANTIAGO, EDGAR M (IDC)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:M
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 SUTTER BUTTES ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2944
Mailing Address - Country:US
Mailing Address - Phone:629-532-5136
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICINE INST
Practice Address - Street 2:34101 FARENHOLT AVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:619-532-5136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman