Provider Demographics
NPI:1689907164
Name:SAMPLE, NEIL BRANDON (OD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:BRANDON
Last Name:SAMPLE
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 1:340 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2624
Mailing Address - Country:US
Mailing Address - Phone:276-628-3118
Mailing Address - Fax:276-628-8342
Practice Address - Street 1:340 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2624
Practice Address - Country:US
Practice Address - Phone:276-628-3118
Practice Address - Fax:276-628-8342
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689907164Medicaid
VAP00924345OtherRAILROAD MEDICARE
VAP00924345OtherRAILROAD MEDICARE
VAVV0589BMedicare PIN