Provider Demographics
NPI:1235236993
Name:TACKE, SAMUEL B (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:B
Last Name:TACKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:123 W NORTH BEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-3420
Mailing Address - Country:US
Mailing Address - Phone:209-722-8161
Mailing Address - Fax:209-383-9211
Practice Address - Street 1:123 W NORTH BEAR CREEK DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3420
Practice Address - Country:US
Practice Address - Phone:209-722-8161
Practice Address - Fax:209-383-9211
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG60593207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A90029Medicare UPIN