Provider Demographics
NPI:1558523910
Name:SAMUELS, DEREK (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:SAMUELS
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 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5890
Mailing Address - Fax:251-471-7925
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:MASTIN 102
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-470-5890
Practice Address - Fax:251-471-7925
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1161982085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program