Provider Demographics
NPI:1114959566
Name:SANTIAGO-RIVERA, MANUEL (OD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:SANTIAGO-RIVERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 AVE PONCE DE LEON
Mailing Address - Street 2:MIRAMAR 9G
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3646
Mailing Address - Country:US
Mailing Address - Phone:787-721-6656
Mailing Address - Fax:787-721-6656
Practice Address - Street 1:925 ROBERTO SANCHEZ VILELLA AVE
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-757-3375
Practice Address - Fax:787-757-3375
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR54728Medicare ID - Type Unspecified