Basic Information
| Provider Information | |||||||||
| NPI: | 1760729131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JORDAN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121808309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182740476 | ||||||||
| FaxNumber: | 5182740497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2013 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 2847000 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 04502787 | 05 | NY | MEDICAID |