Provider Demographics
NPI:1649958075
Name:SAMPSON, RONALD JR (LDO)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:SAMPSON
Suffix:JR
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 HORSEBLOCK RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2543
Mailing Address - Country:US
Mailing Address - Phone:631-776-9043
Mailing Address - Fax:631-286-9485
Practice Address - Street 1:2950 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2543
Practice Address - Country:US
Practice Address - Phone:631-776-9043
Practice Address - Fax:631-286-9485
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009709156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician