Provider Demographics
NPI:1578561221
Name:SAMSON, ROGELIO D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGELIO
Middle Name:D
Last Name:SAMSON
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 1:14 W JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1736
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:14 W JORDAN ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1736
Practice Address - Country:US
Practice Address - Phone:850-436-4630
Practice Address - Fax:850-436-2095
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME28252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066410300Medicaid
17504WMedicare UPIN
FL17504OtherHEALTH OPTIONS
FL592190639OtherEIN / TAX ID NUMBER
FL066410300Medicaid
FL17504Medicare ID - Type UnspecifiedPROVIDER NUMBER
FL17504OtherBCBSFL PROVIDER NUMBER
FLA016OtherVISTA
FL165426OtherWELLCARE HMO