Provider Demographics
NPI:1104443720
Name:DODDA, SAMANTHA A (OD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:A
Last Name:DODDA
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 1:744 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3603
Mailing Address - Country:US
Mailing Address - Phone:812-855-8436
Mailing Address - Fax:
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7617
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011752152W00000X
CA34826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist