Provider Demographics
NPI:1497136139
Name:JOHANSEN, SAMUEL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEE
Last Name:JOHANSEN
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 1:300 BYPASS 25 NE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646
Mailing Address - Country:US
Mailing Address - Phone:864-992-6386
Mailing Address - Fax:
Practice Address - Street 1:214 WALLER AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2747
Practice Address - Country:US
Practice Address - Phone:864-992-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist