=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457450587
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADONNA MARIA SANTOS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 MAIN ST
-----------------------------------------------------
City | AGAWAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01001-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-789-7711
-----------------------------------------------------
Fax | 413-789-1197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 THISTLEDOWN
-----------------------------------------------------
City | SUFFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06078-1639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-668-7618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MA 3468
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------