Provider Demographics
NPI:1154777183
Name:SANTIAGO, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 GRATEN ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6519
Mailing Address - Country:US
Mailing Address - Phone:248-952-4011
Mailing Address - Fax:248-282-0455
Practice Address - Street 1:517 GRATEN ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6519
Practice Address - Country:US
Practice Address - Phone:248-952-4011
Practice Address - Fax:248-282-0455
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820379695305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization