MEDICARE: DR. LETICIA SANTA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3107	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3107	OTHER	CT	FEDERAL GOVERNMENT (VA)

General Provider Information

NPI Number	:	1013558139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LETICIA SANTA OD

Provider Business Mailing Address
First Line	:	999 N SILVER SPRINGS BLVD APT 907
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67212-6036
Country	:	US
Telephone Number	:	413-636-9626
Fax Number	:

Provider Business Practice Location Address
First Line	:	949 S GLENDALE ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-3210
Country	:	US
Telephone Number	:	316-685-2221
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	09/30/2019

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Directions to “ DR. LETICIA SANTA OD” Practice Location

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