Provider Demographics
NPI:1649968918
Name:CALVERT, SAMUEL R
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:CALVERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 NEW TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7966
Mailing Address - Country:US
Mailing Address - Phone:270-606-0269
Mailing Address - Fax:
Practice Address - Street 1:335 NEW TOWNE DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7966
Practice Address - Country:US
Practice Address - Phone:270-842-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6260152W00000X
KY2381DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist