Provider Demographics
NPI:1992770093
Name:PESIN, SAMUEL R (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:PESIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 CRANDON BLVD APT 1103
Mailing Address - Street 2:
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-2546
Mailing Address - Country:US
Mailing Address - Phone:419-351-9859
Mailing Address - Fax:
Practice Address - Street 1:781 CRANDON BLVD APT 1103
Practice Address - Street 2:
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149-2546
Practice Address - Country:US
Practice Address - Phone:419-351-9859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHME122753207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PE0692861OtherPTAN
OH0829296Medicaid
341196311OtherTAX IDENTIFICATION NUMBER
OH000000026317OtherANTHEM
341196311OtherTAX IDENTIFICATION NUMBER
OH000000026317OtherANTHEM