NPIMap

Organization Active NPI

Moderneyes, PLLC

  • Optometrist
  • Charleston, WV
National Provider Identifier
1649933763
Registry record updated May 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
Legal business name
MODERNEYES, PLLC
Practice address
4202 Maccorkle Ave SE
Charleston, WV 25304-2502
Phone
(304) 925-4761
NPI assigned
Oct 15, 2021
Organization subpart
Yes
Parent organization
MODERNEYES, PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 25, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Laura M Suppa Sammons, ODNPI 1235571563
Title
Optometrist
Phone
(304) 545-8366

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X Primary

Addresses

Primary practice location

4202 Maccorkle Ave SE
Charleston, WV 25304-2502

Mailing address

1171 Creekstone RDG
South Charleston, WV 25309-9476
Phone (304) 545-8366

Other identifiers 1

IdentifierTypeStateIssuer
3910005909MedicaidWV

Other names 1

  • Charleston Vision Source Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220308003115 WV Part B Supplier - Clinic/Group Practice 0244624211 Receives reassigned benefits from 2 practitioners
Practice locations: Charleston, WV

National Provider Directory

National Provider Directory
Part of
Moderneyes PLLC

Locations

4202 Maccorkle Ave SE
Charleston, WV 25304
Phone (304) 925-4761

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1634256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1684972800000",
    "number": "1649933763",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1171 CREEKSTONE RDG",
            "city": "SOUTH CHARLESTON",
            "state": "WV",
            "postal_code": "253099476",
            "telephone_number": "304-545-8366"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4202 MACCORKLE AVE SE",
            "city": "CHARLESTON",
            "state": "WV",
            "postal_code": "253042502",
            "telephone_number": "304-925-4761"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERNEYES, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MODERNEYES, PLLC",
        "enumeration_date": "2021-10-15",
        "last_updated": "2023-05-25",
        "certification_date": "2023-05-25",
        "status": "A",
        "authorized_official_last_name": "SUPPA SAMMONS",
        "authorized_official_first_name": "LAURA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OPTOMETRIST",
        "authorized_official_telephone_number": "304-545-8366",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3910005909",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Charleston Vision Source",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charleston, WV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 25, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.