Healthcare Provider Details

I. General information

NPI: 1336294503
Provider Name (Legal Business Name): ANGEL L SANTIAGO COLON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CARR 149 SUITE 255 MANATI SHOPPING CENTER
MANATI PR
00674
US

IV. Provider business mailing address

10 CARR 149 SUITE 255 MANATI SHOPPING CENTER
MANATI PR
00674
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-6222
  • Fax: 787-854-6660
Mailing address:
  • Phone: 787-854-6222
  • Fax: 787-854-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number434
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier434
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerLA JUNTA EXAMINADORA DE O

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: