Provider Demographics
NPI:1306831854
Name:SANTIAGO, WAGNER GILBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:WAGNER
Middle Name:GILBERT
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E GUDE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1496
Mailing Address - Country:US
Mailing Address - Phone:301-933-7133
Mailing Address - Fax:301-933-7137
Practice Address - Street 1:251 WILMOT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4048
Practice Address - Country:US
Practice Address - Phone:704-861-0425
Practice Address - Fax:704-861-0274
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC429213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0802COtherBCBS
SCPDN999Medicaid
9673684OtherCIGNA
9673684002OtherCIGNA
23301OtherWELLPATH
2211451OtherAETNA
27715OtherMAMSI
108614OtherWELLNESS
561552247004OtherPRUDENTIAL
7094015OtherAETNA
32654OtherPARTNERS
108614OtherWELLNESS
2211451OtherAETNA
27715OtherMAMSI
SCPDN999Medicaid