Provider Demographics
NPI:1619948213
Name:MITZ, SAMUEL R (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:MITZ
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 92
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:AL
Mailing Address - Zip Code:35142-0092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1664 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2543
Practice Address - Country:US
Practice Address - Phone:214-535-7079
Practice Address - Fax:214-484-4111
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5468207R00000X
MN64904207R00000X
ND14459208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166418705Medicaid
TX166418707Medicaid
TX0023RROtherBCBS
TX8F21617Medicare PIN
TX0A5387Medicare PIN
TX0A5733Medicare PIN
TXP00664121Medicare PIN
TX613254Medicare PIN
TX0023RROtherBCBS
TXP000664121Medicare PIN
TX613425Medicare PIN