Provider Demographics
NPI:1912951658
Name:DONOFRIO, SAMUEL E (OD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:DONOFRIO
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:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-0398
Mailing Address - Country:US
Mailing Address - Phone:724-527-5884
Mailing Address - Fax:724-527-5914
Practice Address - Street 1:542 LOCUST ST
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-2500
Practice Address - Country:US
Practice Address - Phone:724-527-5884
Practice Address - Fax:724-527-5914
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA630542Medicare PIN
PAU25412Medicare UPIN
PA0733590001Medicare NSC