Provider Demographics
NPI:1467578435
Name:KINROSS, SAMANTHA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:KINROSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:SHEDLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2656 AMBERWICK PL
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-8894
Mailing Address - Country:US
Mailing Address - Phone:614-921-1651
Mailing Address - Fax:
Practice Address - Street 1:5123 TUTTLE CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-1535
Practice Address - Country:US
Practice Address - Phone:614-734-1570
Practice Address - Fax:614-734-1566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4877 T1742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist