Provider Demographics
NPI:1205909926
Name:SANTIAGO, IRMA DELIA (MD)
Entity type:Individual
Prefix:MS
First Name:IRMA
Middle Name:DELIA
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:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-0058
Mailing Address - Country:US
Mailing Address - Phone:939-244-6171
Mailing Address - Fax:787-843-8559
Practice Address - Street 1:635 N ERIE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-5317
Practice Address - Country:US
Practice Address - Phone:419-213-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056699207Q00000X, 2083X0100X
PR16448207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DM165001OtherASSMCA ESTADA LIBRE ASOCI
PR0747688Medicaid
PR0747688Medicaid
BS1510761OtherDEA US FEDERAL GOVT
DM165001OtherASSMCA ESTADA LIBRE ASOCI