Provider Demographics
NPI:1679562052
Name:SANTIAGO, WILDA IVETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:WILDA
Middle Name:IVETTE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CC36 CALLE CEIBAS
Mailing Address - Street 2:ESTANCIAS DE RIO HONDO III
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-3419
Mailing Address - Country:US
Mailing Address - Phone:787-798-3333
Mailing Address - Fax:787-798-6829
Practice Address - Street 1:CC36 CALLE CEIBAS
Practice Address - Street 2:ESTANCIAS DE RIO HONDO III
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-3419
Practice Address - Country:US
Practice Address - Phone:787-798-3333
Practice Address - Fax:787-798-6829
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0058077Medicare ID - Type Unspecified