Provider Demographics
NPI:1053392936
Name:ODLE, SAM WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:WILLIAM
Last Name:ODLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2800 SW WANAMAKER RD
Mailing Address - Street 2:SUITE 192
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-4293
Mailing Address - Country:US
Mailing Address - Phone:785-272-0707
Mailing Address - Fax:785-271-1512
Practice Address - Street 1:3012 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-2809
Practice Address - Country:US
Practice Address - Phone:785-537-1118
Practice Address - Fax:785-537-8005
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS-1199-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS005036OtherBCBS
KS100218020AMedicaid
059825OtherBCBS
410038216OtherMEDICARE RAILROAD
410034609OtherMEDICARE RAILROAD
059825OtherBCBS
410034609OtherMEDICARE RAILROAD
410038216OtherMEDICARE RAILROAD