MEDICARE: SAMUEL WINN 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	OP1132	FL

General Provider Information

NPI Number	:	1649407842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL WINN OD

Provider Business Mailing Address
First Line	:	1813 W NEW HAVEN AVE
Second Line	:
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-3930
Country	:	US
Telephone Number	:	321-951-2220
Fax Number	:	321-722-4751

Provider Business Practice Location Address
First Line	:	1813 W NEW HAVEN AVE
Second Line	:
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-3930
Country	:	US
Telephone Number	:	321-951-2220
Fax Number	:	321-722-4754

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

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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