Provider Demographics
NPI:1265661896
Name:CORNEJO, SANTIAGO M (MD)
Entity type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:M
Last Name:CORNEJO
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 1:3030 N CENTRAL AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2716
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:2902 W AGUA FRIA FWY STE 1000
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3969
Practice Address - Country:US
Practice Address - Phone:480-485-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR713842085R0202X
AZ461202085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR71384OtherTRAINING PERMIT
AZ825984Medicaid
AZ46120OtherMEDICAL LICENSE