Healthcare Provider Details

I. General information

NPI: 1093790131
Provider Name (Legal Business Name): SAMUEL SANTANDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 RANDOLPH ROAD SUITE 100
CHARLOTTE NC
28211
US

IV. Provider business mailing address

PO BOX 1070 CHRISTENBURY EYE CENTER
CHARLOTTE NC
28201-1070
US

V. Phone/Fax

Practice location:
  • Phone: 704-332-9365
  • Fax: 704-364-7384
Mailing address:
  • Phone: 704-332-9365
  • Fax: 704-364-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9800380
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: