Provider Demographics
NPI:1154619021
Name:MOSCOSO MARTINEZ, SANTIAGO FABIAN (MD)
Entity type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:FABIAN
Last Name:MOSCOSO MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:844-832-1956
Mailing Address - Fax:989-633-5241
Practice Address - Street 1:4201 CAMPUS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6128
Practice Address - Country:US
Practice Address - Phone:989-839-6188
Practice Address - Fax:989-839-6221
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301510406207RH0003X
IA44063207RH0003X
NE30205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology