Provider Demographics
NPI:1023376274
Name:SAMUEL, DAVIS RUSSAL (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVIS
Middle Name:RUSSAL
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8902 BLOOMFIELD PL
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4506
Mailing Address - Country:US
Mailing Address - Phone:267-879-0970
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS019189207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine