Provider Demographics
NPI:1609841360
Name:PELLETIER, SAMMY L (OD)
Entity type:Individual
Prefix:DR
First Name:SAMMY
Middle Name:L
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:764 ROUTE ONE
Mailing Address - Street 2:UNIT 6
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-5879
Mailing Address - Country:US
Mailing Address - Phone:207-363-7555
Mailing Address - Fax:207-363-1711
Practice Address - Street 1:764 ROUTE ONE
Practice Address - Street 2:UNIT 6
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-5879
Practice Address - Country:US
Practice Address - Phone:207-363-7555
Practice Address - Fax:207-363-1711
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEOPT729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME018152OtherSTAR #
MEM22891OtherCIGNA PROVIDER #
ME130570000Medicaid
ME2237986OtherAETNA PROV. #
ME30009894OtherNH MEDICAID
MEMNT038OtherHARVARD PILGRIM PROV. #
ME5021708OtherCIGNA PROVIDER #
ME09Y000292ME01OtherBLUE CROSS PROVIDER #
MM4138OtherMEDICARE
ME09Y000292ME01OtherBLUE CROSS PROVIDER #
ME5021708OtherCIGNA PROVIDER #