Basic Information
| Provider Information | |||||||||
| NPI: | 1013019892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO GONZALEZ | ||||||||
| FirstName: | MARISEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTIAGO | ||||||||
| OtherFirstName: | MARISEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21444 CARMEAN WAY | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199474572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028551233 | ||||||||
| FaxNumber: | 3028552025 | ||||||||
| Practice Location | |||||||||
| Address1: | 21444 CARMEAN WAY | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199474572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028552020 | ||||||||
| FaxNumber: | 3028552025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10609 | PR | N | Other Service Providers | Specialist | 208000000X | C1-0009135 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200111611 | 05 | DE | MEDICAID |