Provider Demographics
NPI:1104369842
Name:SAMUEL, MONIQUE M
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 PALM BEACH LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6501
Mailing Address - Country:US
Mailing Address - Phone:561-420-8555
Mailing Address - Fax:561-420-8560
Practice Address - Street 1:2007 PALM BEACH LAKES BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6501
Practice Address - Country:US
Practice Address - Phone:561-420-8555
Practice Address - Fax:561-420-8560
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1976207P00000X
DEOS14132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine