Provider Demographics
NPI:1144237744
Name:SAMUEL, MARK (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 E BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-4110
Mailing Address - Country:US
Mailing Address - Phone:914-777-0097
Mailing Address - Fax:914-381-3199
Practice Address - Street 1:931 E BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-4110
Practice Address - Country:US
Practice Address - Phone:914-777-0097
Practice Address - Fax:914-381-3199
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX8745-1111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX5R851Medicare ID - Type Unspecified
NYU81329Medicare UPIN