Provider Demographics
NPI:1629015284
Name:PALLIN, SAMUEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:L
Last Name:PALLIN
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 1:37900 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TONOPAH
Mailing Address - State:AZ
Mailing Address - Zip Code:85354-9336
Mailing Address - Country:US
Mailing Address - Phone:602-321-7056
Mailing Address - Fax:
Practice Address - Street 1:6500 JEFFERSON ST NE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3489
Practice Address - Country:US
Practice Address - Phone:602-321-7056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8620207W00000X
CAG50285207W00000X
NMMD2007-0210207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD00092Medicare UPIN