Provider Demographics
NPI:1285631796
Name:VERNON, SAMUEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:D
Last Name:VERNON
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 1:1070 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4138
Mailing Address - Country:US
Mailing Address - Phone:276-781-2225
Mailing Address - Fax:276-783-8843
Practice Address - Street 1:1070 TERRACE DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4138
Practice Address - Country:US
Practice Address - Phone:276-781-2225
Practice Address - Fax:276-783-8843
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA202760OtherBLACK LUNG
VA1285631796Medicaid
VAP00197424OtherRAILROAD MEDICARE
VA0385921OtherUNITED MINE WORKERS
VA144631OtherANTHEM
VAVV2321AMedicare PIN