Provider Demographics
NPI:1386916641
Name:SANTOS, HERMOGENES SANTIAGO (MD)
Entity type:Individual
Prefix:
First Name:HERMOGENES
Middle Name:SANTIAGO
Last Name:SANTOS
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 1:171 E 84TH ST
Mailing Address - Street 2:APT. 12F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2000
Mailing Address - Country:US
Mailing Address - Phone:212-288-7612
Mailing Address - Fax:
Practice Address - Street 1:171 E 84TH ST
Practice Address - Street 2:APT. 12F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2000
Practice Address - Country:US
Practice Address - Phone:212-288-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1372552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLICENSE NUMBER 13725OtherLICENSE