Provider Demographics
NPI:1790353308
Name:BERTHERMAN, SAMANTHA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:BERTHERMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3534
Mailing Address - Country:US
Mailing Address - Phone:401-595-8695
Mailing Address - Fax:
Practice Address - Street 1:1466 BROAD ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2836
Practice Address - Country:US
Practice Address - Phone:401-941-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIODTG00717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program