Provider Demographics
NPI:1750580148
Name:SANTIAGO, JEANINE (MD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
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 1:124 SMITHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-2452
Mailing Address - Country:US
Mailing Address - Phone:845-896-7712
Mailing Address - Fax:845-592-0328
Practice Address - Street 1:124 SMITHTOWN RD
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2452
Practice Address - Country:US
Practice Address - Phone:845-896-7712
Practice Address - Fax:845-592-0328
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY181053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY181053OtherLICENSE NEW YORK
NY01366898Medicaid
NY78K861Medicare PIN
NYNY181053OtherLICENSE NEW YORK