Provider Demographics
NPI:1598717860
Name:SAMPLES, JOHN RANDALL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:SAMPLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5030
Mailing Address - Country:US
Mailing Address - Phone:360-456-4800
Mailing Address - Fax:360-456-4812
Practice Address - Street 1:215 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5030
Practice Address - Country:US
Practice Address - Phone:360-456-4800
Practice Address - Fax:360-456-4800
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 13791207W00000X
WAMD00030114207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR289959Medicaid
WA360398OtherL&I
WA2044175Medicaid
180040576OtherRAILROAD MEDICARE
180040576OtherRAILROAD MEDICARE
OR107535Medicare ID - Type Unspecified