Provider Demographics
NPI:1285644955
Name:SAMUEL, RICHARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8880 N. HESS ST.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-772-5204
Mailing Address - Fax:208-772-5275
Practice Address - Street 1:8880 N HESS ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8716
Practice Address - Country:US
Practice Address - Phone:208-772-5204
Practice Address - Fax:208-772-5275
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF38378Medicare UPIN