Provider Demographics
NPI:1063257269
Name:KNOBLAUCH, SAMANTHA JO (OD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:KNOBLAUCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1660 GENESSEE ST UNIT 506
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64102-1146
Mailing Address - Country:US
Mailing Address - Phone:316-670-3763
Mailing Address - Fax:
Practice Address - Street 1:9401 N OAK TRFY STE 124
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-3393
Practice Address - Country:US
Practice Address - Phone:816-478-1230
Practice Address - Fax:816-350-6801
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024023446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist