Provider Demographics
NPI:1639133911
Name:SAMPANIS, PERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:
Last Name:SAMPANIS
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 1:2806 E PINE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4424
Mailing Address - Country:US
Mailing Address - Phone:812-334-3377
Mailing Address - Fax:
Practice Address - Street 1:2806 E PINE LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4424
Practice Address - Country:US
Practice Address - Phone:812-334-3377
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001565A&B152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU28559Medicare UPIN
IN435950Medicare ID - Type Unspecified