MEDICARE: MODERNEYES, PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649933763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERNEYES, PLLC

Provider Business Mailing Address
First Line	:	1171 CREEKSTONE RDG
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-9476
Country	:	US
Telephone Number	:	304-545-8366
Fax Number	:

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	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. LAURA M SUPPA SAMMONS
Credential	:	OD
Telephone Number	:	304-545-8366

Provider Enumeration Date	:	10/15/2021
Last Update Date	:	05/25/2023

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