Provider Demographics
NPI:1235571563
Name:SUPPA SAMMONS, LAURA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:MARIE
Last Name:SUPPA SAMMONS
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 1:4202 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2502
Mailing Address - Country:US
Mailing Address - Phone:304-925-4761
Mailing Address - Fax:304-925-0310
Practice Address - Street 1:4202 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2502
Practice Address - Country:US
Practice Address - Phone:304-925-4761
Practice Address - Fax:304-925-0310
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2002-IOD1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV4554AMedicare PIN