Provider Demographics
NPI:1063457547
Name:OVERSTREET, SAMUEL JOSEPH IV (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:OVERSTREET
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4720 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6292
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:2 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5810
Practice Address - Country:US
Practice Address - Phone:912-352-7941
Practice Address - Fax:912-352-7946
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1788152W00000X
GAOPT002201152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00314277BMedicaid
GA202I413664Medicare PIN
OK248622801Medicare PIN
OKP00376543OtherMEDICARE ID
OK200088800AMedicaid
OKB09631Medicare UPIN