Provider Demographics
NPI:1104954924
Name:WAPNER, SAMUEL M (OD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:M
Last Name:WAPNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1166
Mailing Address - Country:US
Mailing Address - Phone:248-332-2895
Mailing Address - Fax:248-332-2896
Practice Address - Street 1:22 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1166
Practice Address - Country:US
Practice Address - Phone:248-332-2895
Practice Address - Fax:248-332-2896
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F36693OtherBCBS OF MI
MI945105462Medicaid
MIP59190001Medicare PIN
MI0155530001Medicare NSC
MIU23840Medicare UPIN