Provider Demographics
NPI:1629082250
Name:ERWIN, SAMUEL L
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:ERWIN
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-0037
Mailing Address - Country:US
Mailing Address - Phone:870-857-6556
Mailing Address - Fax:870-857-3787
Practice Address - Street 1:609 N MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-1617
Practice Address - Country:US
Practice Address - Phone:870-857-6556
Practice Address - Fax:870-857-3787
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2293152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR291690OtherPTAN
AR101510722Medicaid
AR101510722Medicaid
AR6794710001Medicare NSC