Healthcare Provider Details

I. General information

NPI: 1144363714
Provider Name (Legal Business Name): MYRIAM M SANTIAGO OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 CALLE MAYOR ZAMORA BUILDING FIRST FLOOR
PONCE PR
00730-3728
US

IV. Provider business mailing address

44 MAYOR STREET ZAMORA BUILDING FIRST FLOOR
PONCE PR
00730-3761
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-8175
  • Fax: 787-259-4462
Mailing address:
  • Phone: 787-844-8175
  • Fax: 787-259-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number135
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: