Provider Demographics
NPI:1902329238
Name:SAM, KRISTINE THAO (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:THAO
Last Name:SAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2895
Mailing Address - Country:US
Mailing Address - Phone:504-355-6026
Mailing Address - Fax:
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5265
Practice Address - Country:US
Practice Address - Phone:504-355-6026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist