MEDICARE: DR. HECTOR CARLOS SANTIAGO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	139-397	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	139-397	OTHER	PR	PR BOARD OF OPTOMETRY LICENSES

General Provider Information

NPI Number	:	1093199614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HECTOR CARLOS SANTIAGO O.D.

Provider Business Mailing Address
First Line	:	500 JOHN WILL HARRIS
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00957-6257
Country	:	US
Telephone Number	:	787-765-1915
Fax Number	:	787-765-9854

Provider Business Practice Location Address
First Line	:	500 JOHN WILL HARRIS
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00957-6257
Country	:	US
Telephone Number	:	787-765-1915
Fax Number	:	787-765-9854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2015
Last Update Date	:	07/14/2015

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