MEDICARE: DR. LAURA MARIE SUPPA SAMMONS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2002-IOD1	WV

General Provider Information

NPI Number	:	1235571563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA MARIE SUPPA SAMMONS OD

Provider Business Mailing Address
First Line	:	4202 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-2502
Country	:	US
Telephone Number	:	304-925-4761
Fax Number	:	304-925-0310

Provider Business Practice Location Address
First Line	:	4202 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-2502
Country	:	US
Telephone Number	:	304-925-4761
Fax Number	:	304-925-0310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	01/12/2022

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