Provider Demographics
NPI:1265026470
Name:BURRILL, SAMANTHA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MARIE
Last Name:BURRILL
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 1:743 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4419
Mailing Address - Country:US
Mailing Address - Phone:207-799-3031
Mailing Address - Fax:
Practice Address - Street 1:743 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4419
Practice Address - Country:US
Practice Address - Phone:207-799-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT1038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist