Provider Demographics
NPI:1457342149
Name:SANTIVIAGO, ANDRES G (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:G
Last Name:SANTIVIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11012 E 13 MILE RD
Mailing Address - Street 2:STE 212
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2572
Mailing Address - Country:US
Mailing Address - Phone:586-582-7150
Mailing Address - Fax:586-582-7164
Practice Address - Street 1:11012 E 13 MILE RD
Practice Address - Street 2:STE 212
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2572
Practice Address - Country:US
Practice Address - Phone:586-582-7150
Practice Address - Fax:586-582-7164
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035546207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI407185110Medicaid
B45141Medicare UPIN
MI407185110Medicaid