Provider Demographics
NPI:1538302344
Name:SAMUEL, KRYSTAL THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:THOMAS
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:SARA
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128
Mailing Address - Country:US
Mailing Address - Phone:503-435-1200
Mailing Address - Fax:503-434-9572
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-435-1200
Practice Address - Fax:503-274-5400
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO172095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500690584Medicaid