Provider Demographics
NPI:1235493867
Name:FERNANDEZ-SANTIAGO, MARA LIZ (MD)
Entity type:Individual
Prefix:DR
First Name:MARA
Middle Name:LIZ
Last Name:FERNANDEZ-SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1523
Mailing Address - Country:US
Mailing Address - Phone:614-754-5500
Mailing Address - Fax:
Practice Address - Street 1:3400 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1523
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:414-805-6980
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75160207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235493867Medicaid