Basic Information
| Provider Information | |||||||||
| NPI: | 1003003856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117762568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317326984 | ||||||||
| FaxNumber: | 6317327019 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117763336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317326984 | ||||||||
| FaxNumber: | 6317327019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 217808 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02162494 | 05 | NY | MEDICAID |