Provider Demographics
NPI:1801865936
Name:REISS, SAMUEL L (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:REISS
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:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:1650 S UNION AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4349
Practice Address - Country:US
Practice Address - Phone:330-821-2020
Practice Address - Fax:330-823-2224
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3306/T610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0348378Medicaid
OHT82011Medicare UPIN
OH0428750001Medicare NSC
OHRE0632254Medicare PIN
OH0348378Medicaid