Provider Demographics
NPI:1326499187
Name:DOLEZAL, SAMUEL JOSEPH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:DOLEZAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 OLD JEFFERSON RD BLDG 700
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1465
Mailing Address - Country:US
Mailing Address - Phone:706-353-2990
Mailing Address - Fax:706-353-2992
Practice Address - Street 1:3320 OLD JEFFERSON RD STE 600
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1463
Practice Address - Country:US
Practice Address - Phone:706-353-2990
Practice Address - Fax:706-353-2992
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN65020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty