Basic Information
| Provider Information | |||||||||
| NPI: | 1144216185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | JULIO | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 NW 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ALEDO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095823789 | ||||||||
| FaxNumber: | 3095823735 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 NW 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ALEDO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095823789 | ||||||||
| FaxNumber: | 3095823735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036093955 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006632002 | 01 | IL | BLUE CROSS OF IL | OTHER | 371352599001 | 05 | IL | MEDICAID | 366007544007 | 05 | IL | MEDICAID |