Provider Demographics
NPI:1205871357
Name:SANTIAGO, AMELIA J (MD)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:J
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 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:202 LARRY JOE HARLESS DRIVE, SUITE 205
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621-1842
Practice Address - Country:US
Practice Address - Phone:304-664-6270
Practice Address - Fax:304-664-6272
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21670208000000X
WV12861208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0112321000Medicaid
KY65920951Medicaid
WV2034522Medicare PIN
WVWV1834B662Medicare Oscar/Certification
KY0504210Medicare ID - Type Unspecified
KYF10506Medicare UPIN
WVWV1834AMedicare Oscar/Certification
WV2034525Medicare PIN
WVWV1834BMedicare Oscar/Certification
WV2034523Medicare PIN
WVWV1834CMedicare Oscar/Certification
WVWV1834B663Medicare Oscar/Certification
WV2034524Medicare PIN
KY65920951Medicaid