=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134578461
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL JAMES MENEI O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2016
-----------------------------------------------------
Last Update Date | 02/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 223 E MAIN ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19709-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-376-4190
-----------------------------------------------------
Fax | 302-376-5644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 W FLAGSTONE DR
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19702-3647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-312-9725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG003188
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00667000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | I3-0001393
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------