Provider Demographics
NPI:1497041008
Name:DAVID L. SAMUEL, M.D. A PROFFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DAVID L. SAMUEL, M.D. A PROFFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-624-6650
Mailing Address - Street 1:233 SAINT ANN DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3395
Mailing Address - Country:US
Mailing Address - Phone:985-624-6650
Mailing Address - Fax:985-674-3634
Practice Address - Street 1:233 SAINT ANN DR
Practice Address - Street 2:SUITE 3
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3395
Practice Address - Country:US
Practice Address - Phone:985-624-6650
Practice Address - Fax:985-674-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10711R261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1991562Medicaid
LAB56264Medicare UPIN