Provider Demographics
NPI:1124089313
Name:SANTIAGO, CAMILO (MD)
Entity type:Individual
Prefix:DR
First Name:CAMILO
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CAMILO
Other - Middle Name:S
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-289-6381
Practice Address - Fax:765-448-7646
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237102208600000X
KY47614208600000X
IN01081449A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021456Medicaid
IN090540392OtherMEDICARE