Provider Demographics
NPI:1235204694
Name:SAMJI, NIMIRA (OD)
Entity Type:Individual
Prefix:
First Name:NIMIRA
Middle Name:
Last Name:SAMJI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ENDICOTT ST
Mailing Address - Street 2:ENDICOTT PLAZA
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2515
Mailing Address - Country:US
Mailing Address - Phone:978-777-4700
Mailing Address - Fax:978-750-0862
Practice Address - Street 1:139 ENDICOTT ST
Practice Address - Street 2:ENDICOTT PLAZA
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2515
Practice Address - Country:US
Practice Address - Phone:978-777-4700
Practice Address - Fax:978-750-0862
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010253152W00000X
MA4108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0335771Medicaid
MAW16375OtherBCBS
MA4108OtherMASSACHUSETTS OPTOMETRY LICENSE
IL346003017OtherILLINOIS CONTROLLED SUBSTANCE
IL046010253OtherILLINOIS OPTOMETRY LICENSE
IL346003017OtherILLINOIS CONTROLLED SUBSTANCE
MA0335771Medicaid