Provider Demographics
NPI:1154324879
Name:PERSON, SAMUEL WINFRED (DPM)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:WINFRED
Last Name:PERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2112
Mailing Address - Country:US
Mailing Address - Phone:804-732-1211
Mailing Address - Fax:804-733-5946
Practice Address - Street 1:2020 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2112
Practice Address - Country:US
Practice Address - Phone:804-732-1211
Practice Address - Fax:804-733-5946
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
VA0103000377213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9331409Medicaid
VAT19134Medicare UPIN
VA480000575Medicare ID - Type Unspecified