Provider Demographics
NPI:1528097268
Name:SANTIAGO, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:AILEEN
Other - Last Name:SANTIAGO-SUBORA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:600 JEFFERSON ST STE 404
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6991
Mailing Address - Country:US
Mailing Address - Phone:281-346-0018
Mailing Address - Fax:281-346-0913
Practice Address - Street 1:7629 TIKI DR
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-1548
Practice Address - Country:US
Practice Address - Phone:281-346-0018
Practice Address - Fax:281-346-0913
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078574207Q00000X
TXN2775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I20416Medicare UPIN