Provider Demographics
NPI:1629479563
Name:SAMUEL, JAIMIE VETTICHIRA (DO)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:VETTICHIRA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ELMSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:10523-3726
Mailing Address - Country:US
Mailing Address - Phone:914-409-3103
Mailing Address - Fax:
Practice Address - Street 1:25 SMITH ST FL 2
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2912
Practice Address - Country:US
Practice Address - Phone:845-623-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205729208000000X
NY280311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics