Provider Demographics
NPI:1649407842
Name:WINN, SAMUEL (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WINN
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 1:1813 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3930
Mailing Address - Country:US
Mailing Address - Phone:321-951-2220
Mailing Address - Fax:321-722-4751
Practice Address - Street 1:1813 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3930
Practice Address - Country:US
Practice Address - Phone:321-951-2220
Practice Address - Fax:321-722-4754
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP1132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist