Provider Demographics
NPI:1558715623
Name:SAMUELS, GABRIELLE FAYTH (DO)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:FAYTH
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:FAYTH
Other - Last Name:ROZENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:217 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1162
Practice Address - Country:US
Practice Address - Phone:973-939-6215
Practice Address - Fax:973-290-8345
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10492600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine