Provider Demographics
NPI:1417180852
Name:SAMUEL, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
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 1:156 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-637-3131
Mailing Address - Fax:
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1229
Practice Address - Country:US
Practice Address - Phone:585-637-3131
Practice Address - Fax:585-395-6036
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254678207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology