Provider Demographics
NPI:1477502086
Name:DONTA, SAM T (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:T
Last Name:DONTA
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:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541
Mailing Address - Country:US
Mailing Address - Phone:508-548-8989
Mailing Address - Fax:508-548-5789
Practice Address - Street 1:90 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2533
Practice Address - Country:US
Practice Address - Phone:508-539-6666
Practice Address - Fax:508-540-0133
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30022207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA030022OtherTUFTS HEALTH
MA3016587Medicaid
MA66274UHOtherHARVARD PILGRIM
MA030022OtherTUFTS HEALTH
MAL07130Medicare ID - Type Unspecified