Provider Demographics
NPI:1437250917
Name:DIVAKER, SAMUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:DIVAKER
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 1:13506 SUMMERPORT VILLAGE PKWY # 334
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:407-615-5005
Mailing Address - Fax:678-553-0329
Practice Address - Street 1:6551 N ORANGE BLOSSOM TRL STE 229
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-7018
Practice Address - Country:US
Practice Address - Phone:352-383-8384
Practice Address - Fax:678-553-0329
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90893208000000X
FLMD90893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270372600Medicaid