Basic Information
Provider Information
NPI: 1003003856
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SANTIAGO
FirstName: CYNTHIA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X217808NYY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
0216249405NY MEDICAID


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