Provider Demographics
NPI:1619911385
Name:JESUDASS, SAMSON (MD)
Entity Type:Individual
Prefix:
First Name:SAMSON
Middle Name:
Last Name:JESUDASS
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 1:950 PECAN STREET
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201, WEST 38TH STREET,MEDICAL DIRECTOR
Practice Address - Street 2:SETON MEDICAL CENTER ,,ADMIN
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1006
Practice Address - Country:US
Practice Address - Phone:512-324-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3262207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113783804Medicaid
TX113783804Medicaid
TXP00301702Medicare PIN
TXG49398Medicare UPIN