Provider Demographics
NPI:1316154875
Name:SANTIAGO-BAROUHAS, IVELISSE (MD)
Entity type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:
Last Name:SANTIAGO-BAROUHAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IVELISSE
Other - Middle Name:DEL CARMEN
Other - Last Name:SANTIAGO-COLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:956-388-6000
Mailing Address - Fax:956-289-2956
Practice Address - Street 1:1102 W TRENTON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-9105
Practice Address - Country:US
Practice Address - Phone:956-388-6000
Practice Address - Fax:956-289-2956
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9042208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135088604Medicaid
TX1F7941OtherMEDICARE PTAN
TX135088608Medicaid
TX135088609Medicaid
TX1F7941OtherMEDICARE
TX135088610Medicaid