Provider Demographics
NPI:1982086484
Name:HEATER, SAMANTHA (OD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HEATER
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 1:5100 W TAFT RD
Mailing Address - Street 2:STE 4M
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3810
Mailing Address - Country:US
Mailing Address - Phone:781-312-9039
Mailing Address - Fax:781-321-8611
Practice Address - Street 1:4109 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1956
Practice Address - Country:US
Practice Address - Phone:781-312-9039
Practice Address - Fax:781-321-8611
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist