Healthcare Provider Details

I. General information

NPI: 1770206369
Provider Name (Legal Business Name): SAMANTHA MYERS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SR-77
SOUTHSIDE AL
35907
US

IV. Provider business mailing address

1312 SR-77
SOUTHSIDE AL
35907
US

V. Phone/Fax

Practice location:
  • Phone: 256-907-2045
  • Fax: 256-907-2313
Mailing address:
  • Phone: 256-907-2045
  • Fax: 256-907-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-E97
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: