Provider Demographics
NPI:1538804109
Name:SANTOS UTATE, CLARALIZ
Entity type:Individual
Prefix:
First Name:CLARALIZ
Middle Name:
Last Name:SANTOS UTATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3182
Mailing Address - Country:US
Mailing Address - Phone:347-720-0844
Mailing Address - Fax:
Practice Address - Street 1:4930 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3182
Practice Address - Country:US
Practice Address - Phone:347-720-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000000152W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty