Provider Demographics
NPI:1669465969
Name:SAMAK, SRINIVAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:P
Last Name:SAMAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 LAKELAND HILLS BLVD
Mailing Address - Street 2:STE 4
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3257
Mailing Address - Country:US
Mailing Address - Phone:863-688-3674
Mailing Address - Fax:863-616-9902
Practice Address - Street 1:1500 LAKELAND HILLS BLVD
Practice Address - Street 2:STE 4
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3257
Practice Address - Country:US
Practice Address - Phone:863-688-3674
Practice Address - Fax:863-616-9902
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0028681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D58694Medicare UPIN
FL79197Medicare ID - Type Unspecified