Provider Demographics
NPI:1164422119
Name:SAMUELS, BRUCE S (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-1847
Mailing Address - Country:US
Mailing Address - Phone:985-871-4910
Mailing Address - Fax:985-871-9796
Practice Address - Street 1:189 GREENBRIAR BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7234
Practice Address - Country:US
Practice Address - Phone:985-871-8920
Practice Address - Fax:985-871-9796
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1146498Medicaid
LA5M206CX56Medicare PIN
LAB61706Medicare UPIN