Basic Information
| Provider Information | |||||||||
| NPI: | 1104954924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAPNER | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 N TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483322895 | ||||||||
| FaxNumber: | 2483322896 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 N TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483322895 | ||||||||
| FaxNumber: | 2483322896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002536 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 900F36693 | 01 | MI | BCBS OF MI | OTHER | 945105462 | 05 | MI | MEDICAID |