Provider Demographics
NPI:1174547970
Name:SANTIAGO, MIQUEL ANGEL
Entity type:Individual
Prefix:
First Name:MIQUEL
Middle Name:ANGEL
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70365
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36107-0365
Mailing Address - Country:US
Mailing Address - Phone:334-420-5001
Mailing Address - Fax:334-420-0146
Practice Address - Street 1:1845 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36107-2613
Practice Address - Country:US
Practice Address - Phone:334-263-2301
Practice Address - Fax:334-263-0886
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7279208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51004314OtherBCBS
ALP00192500OtherRAILROAD
AL630900003Medicaid
AL000004314Medicare ID - Type Unspecified
AL630900003Medicaid