Provider Demographics
NPI:1013045863
Name:SAMSON, PRUDENCIO GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCIO
Middle Name:GABRIEL
Last Name:SAMSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:SAMSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:720 SUNRISE AVE STE 202C
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4509
Mailing Address - Country:US
Mailing Address - Phone:860-881-0878
Mailing Address - Fax:
Practice Address - Street 1:720 SUNRISE AVE STE 202C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4509
Practice Address - Country:US
Practice Address - Phone:530-341-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0342092084P0800X
CAC531912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU381AMedicare PIN