Provider Demographics
NPI:1629075072
Name:MAYNARD, SAMUEL LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LOUIS
Last Name:MAYNARD
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 1:1112 E WEISGARBER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2647
Mailing Address - Country:US
Mailing Address - Phone:865-558-9862
Mailing Address - Fax:865-584-3478
Practice Address - Street 1:1112 E WEISGARBER RD STE 102
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2647
Practice Address - Country:US
Practice Address - Phone:865-558-9862
Practice Address - Fax:865-584-3478
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN340932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3706632OtherMEDICARE GROUP #
TN3852807Medicaid
TN3852806Medicaid
TN3852806Medicaid
TN3852807Medicare PIN
TN3706632OtherMEDICARE GROUP #
TN3852808Medicare PIN