=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912195785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER A SANTISI OD PL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2007
-----------------------------------------------------
Last Update Date | 04/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 N COURTENAY PKWY SUITE 12
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-453-1657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 NEW HAMPTON WAY
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-720-4572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PETER A SANTISI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 321-453-1657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | OPC4171
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------