Provider Demographics
NPI:1356632962
Name:SAMUEL, SUHAS JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUHAS
Middle Name:JOE
Last Name:SAMUEL
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 1:4705 S 129TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-7005
Mailing Address - Country:US
Mailing Address - Phone:918-615-7310
Mailing Address - Fax:
Practice Address - Street 1:2720 QUIKTRIP WAY
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3504
Practice Address - Country:US
Practice Address - Phone:470-582-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072465207QS0010X
MO2015013292207Q00000X
TN51765207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program