Provider Demographics
NPI:1871621136
Name:SANTA INES, LATA (MD)
Entity type:Individual
Prefix:
First Name:LATA
Middle Name:
Last Name:SANTA INES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 SANDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-4425
Mailing Address - Country:US
Mailing Address - Phone:224-231-7335
Mailing Address - Fax:
Practice Address - Street 1:373 SUMMIT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120
Practice Address - Country:US
Practice Address - Phone:847-888-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151048207V00000X
WI49654207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124106Medicaid