Provider Demographics
NPI:1093442121
Name:SAMMON, BLAZE (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAZE
Middle Name:
Last Name:SAMMON
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 1:209 HILL ST
Mailing Address - Street 2:
Mailing Address - City:NIAGARA
Mailing Address - State:WI
Mailing Address - Zip Code:54151-1411
Mailing Address - Country:US
Mailing Address - Phone:616-710-9939
Mailing Address - Fax:
Practice Address - Street 1:3501 MCFARLAND BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-2419
Practice Address - Country:US
Practice Address - Phone:205-556-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-F07-TA-C67152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist