Provider Demographics
NPI:1740668607
Name:ROSEN, SAMANTHA (OD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ROSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:FORDYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE
Practice Address - Street 2:SUITE 5101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2514
Practice Address - Country:US
Practice Address - Phone:616-526-7260
Practice Address - Fax:616-267-2606
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004951152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist