Provider Demographics
NPI:1356069900
Name:SANTIAGO, ANGELO JOVITO CAEZAR SANTOS
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:JOVITO CAEZAR SANTOS
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2807
Mailing Address - Country:US
Mailing Address - Phone:714-823-0069
Mailing Address - Fax:
Practice Address - Street 1:17782 COWAN
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6030
Practice Address - Country:US
Practice Address - Phone:949-722-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021619363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health