Provider Demographics
NPI:1164651998
Name:PHELPS, SAMUEL ADAM (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADAM
Last Name:PHELPS
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 1:668 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3951
Mailing Address - Country:US
Mailing Address - Phone:731-424-2414
Mailing Address - Fax:
Practice Address - Street 1:138 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2323
Practice Address - Country:US
Practice Address - Phone:731-989-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001863152W00000X
TN2957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist