Provider Demographics
NPI:1457448797
Name:SANTESSON, DIANE SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:SUSAN
Last Name:SANTESSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:STE. 168
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-413-7022
Mailing Address - Fax:503-413-7066
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:STE. 168
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-7022
Practice Address - Fax:503-413-7066
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-472152W00000X
OR3256T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1145OtherUHA (380 HUKU LII, #107)
HI0000213205OtherHMSA (380 HUKU LII, #107)
HI087295-01Medicaid
HI0000213207OtherHMSA (KAISER ADDRESS)
HIH100391Medicare ID - Type Unspecified380 HUKU LII PL. STE 107
HI087295-01Medicaid