Provider Demographics
NPI:1891785564
Name:SAMUEL, JENNIFER L (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:SAMUEL
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 1:940 N SWITZER CYN DR
Mailing Address - Street 2:#101
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4852
Mailing Address - Country:US
Mailing Address - Phone:928-774-7949
Mailing Address - Fax:928-774-7207
Practice Address - Street 1:940 N SWITZER CYN DR
Practice Address - Street 2:#101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4852
Practice Address - Country:US
Practice Address - Phone:928-774-7949
Practice Address - Fax:928-774-7207
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1263152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ790677Medicaid
NM48524047OtherMEDICAID
AZD00087920OtherRAILROAD
U86540Medicare UPIN
AZ790677Medicaid