Provider Demographics
NPI:1891159711
Name:LOPEZ, SANTIAGO ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:ALEXANDER
Last Name:LOPEZ
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 1:303 MAIN ST APT 407
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1449
Mailing Address - Country:US
Mailing Address - Phone:973-856-4652
Mailing Address - Fax:
Practice Address - Street 1:9525 QUEENS BLVD FRNT 5
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1995
Practice Address - Country:US
Practice Address - Phone:718-575-9595
Practice Address - Fax:718-575-8456
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311183208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery