Provider Demographics
NPI:1942311774
Name:GHANNAM, SAMI K (OD)
Entity type:Individual
Prefix:DR
First Name:SAMI
Middle Name:K
Last Name:GHANNAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:SAMI
Other - Middle Name:K
Other - Last Name:GHANNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4008
Mailing Address - Country:US
Mailing Address - Phone:301-725-0607
Mailing Address - Fax:301-725-0294
Practice Address - Street 1:612 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4008
Practice Address - Country:US
Practice Address - Phone:301-725-0607
Practice Address - Fax:301-725-0294
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001157152W00000X
MDTA1759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U87429Medicare UPIN
MD491421Medicare ID - Type Unspecified