Provider Demographics
NPI:1457450587
Name:SANTOS, MADONNA MARIA (OD)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:MARIA
Last Name:SANTOS
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 1:101 THISTLEDOWN
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1639
Mailing Address - Country:US
Mailing Address - Phone:860-668-7618
Mailing Address - Fax:
Practice Address - Street 1:170 MAIN ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1803
Practice Address - Country:US
Practice Address - Phone:413-789-7711
Practice Address - Fax:413-789-1197
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA 3468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA693256OtherUNICARE
MA0000000-21044OtherBMC
MA2665909OtherAETNA
MA16192OtherHEALTH NEW ENGLAND
MA152833OtherHARVARD PILGRIM
MA9780602Medicaid
MA465625OtherCONNECTICARE
MA763273OtherTUFTS
MABLUE CROSS/SHIELDOtherW20299
MADD3718OtherRAILROAD MEDICARE
MA152833OtherHARVARD PILGRIM
MAU55061Medicare UPIN