Provider Demographics
NPI:1487401907
Name:SANTIAGO HERNANDEZ, CRISTAL
Entity type:Individual
Prefix:
First Name:CRISTAL
Middle Name:
Last Name:SANTIAGO HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2363
Mailing Address - Country:US
Mailing Address - Phone:860-793-3500
Mailing Address - Fax:
Practice Address - Street 1:43 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2363
Practice Address - Country:US
Practice Address - Phone:860-793-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNONE207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty