Provider Demographics
NPI:1043506488
Name:WINSTON, SAMUEL JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:WINSTON
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 BROADLEAF CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-2135
Mailing Address - Country:US
Mailing Address - Phone:757-285-1221
Mailing Address - Fax:
Practice Address - Street 1:USS GONZALEZ DDG 66
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09570-1284
Practice Address - Country:US
Practice Address - Phone:757-445-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman