Provider Demographics
NPI:1275030025
Name:SANTILLAN, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:SANTILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13713 STATE HIGHWAY 249
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77086-2705
Mailing Address - Country:US
Mailing Address - Phone:832-288-2661
Mailing Address - Fax:
Practice Address - Street 1:13713 STATE HIGHWAY 249
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77086-2705
Practice Address - Country:US
Practice Address - Phone:832-209-0939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician