Provider Demographics
NPI:1457644833
Name:BACALLAO, SAMUEL EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:EDUARDO
Last Name:BACALLAO
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 1:7522 SW 135TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-3250
Mailing Address - Country:US
Mailing Address - Phone:305-281-2632
Mailing Address - Fax:
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2197
Practice Address - Country:US
Practice Address - Phone:786-596-3621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME123449207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program