Provider Demographics
NPI:1043221799
Name:WEBB, SAMUEL JASON (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JASON
Last Name:WEBB
Suffix:
Gender:M
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:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-0279
Mailing Address - Country:US
Mailing Address - Phone:479-632-3939
Mailing Address - Fax:479-632-3938
Practice Address - Street 1:909 HIGHWAY 71 N
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-5160
Practice Address - Country:US
Practice Address - Phone:479-632-3939
Practice Address - Fax:479-632-3938
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49793GA37OtherGROUP MEMBER PTAN
AR145466722Medicaid
AR145466722Medicaid
AR6683390001Medicare NSC