Provider Demographics
NPI:1073639118
Name:SAMUEL G. MALLER M.D., P.C.
Entity Type:Organization
Organization Name:SAMUEL G. MALLER M.D., P.C.
Other - Org Name:ODENTON FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-675-6589
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-0709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3305 N LEISURE WORLD BLVD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-1367
Practice Address - Country:US
Practice Address - Phone:301-598-1590
Practice Address - Fax:301-598-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG57852Medicare UPIN
DC490827Medicare ID - Type Unspecified