Provider Demographics
NPI:1164006011
Name:CLAXTON, SAMANTHA LEE (OD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:CLAXTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 207173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:3820 PLEASANT HILL RD STE 5
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1429
Practice Address - Country:US
Practice Address - Phone:770-476-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3744152W00000X
390200000X
GAOPT003402152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program