Provider Demographics
NPI:1245929140
Name:BLANKE, SAMANTHA ANN (OD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ANN
Last Name:BLANKE
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 1:3405 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-9664
Mailing Address - Country:US
Mailing Address - Phone:920-905-2836
Mailing Address - Fax:
Practice Address - Street 1:2174 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2972
Practice Address - Country:US
Practice Address - Phone:859-341-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORATI4665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program