Provider Demographics
NPI:1104211986
Name:FAM, SAMUEL DAVID (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:FAM
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 1:1790 BROADWAY STE 1802
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1471
Mailing Address - Country:US
Mailing Address - Phone:212-530-0624
Mailing Address - Fax:212-867-4353
Practice Address - Street 1:1790 BROADWAY STE 1802
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-530-0624
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295422207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program