Provider Demographics
NPI:1457502114
Name:SANTIAGO, ERIC LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LAWRENCE
Last Name:SANTIAGO
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:PSC 80 BOX 13985
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 482
Practice Address - Street 2:C/O INTERNAL MEDICINE CLINIC
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-1600
Practice Address - Country:US
Practice Address - Phone:315-643-7714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.096317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3130123Medicaid
OH4314141Medicare PIN
OH4314142Medicare PIN