Provider Demographics
NPI:1174902571
Name:NELISSA J SANTIAGO
Entity type:Organization
Organization Name:NELISSA J SANTIAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NELISSA
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-269-2099
Mailing Address - Street 1:4 CALLE 1
Mailing Address - Street 2:URB. LA CAMPINA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-9635
Mailing Address - Country:US
Mailing Address - Phone:787-269-2099
Mailing Address - Fax:787-998-9057
Practice Address - Street 1:725 WEST MAIN AVE
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-4201
Practice Address - Country:US
Practice Address - Phone:787-269-2099
Practice Address - Fax:787-998-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR435-020261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========7Medicare NSC