Provider Demographics
NPI:1508253998
Name:LAURENCIN, SAMUEL J (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:LAURENCIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CHASE PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3346
Mailing Address - Country:US
Mailing Address - Phone:203-755-6677
Mailing Address - Fax:
Practice Address - Street 1:500 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3346
Practice Address - Country:US
Practice Address - Phone:203-755-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA282565207X00000X
CT69456207X00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110162087AMedicaid