Provider Demographics
NPI:1669507505
Name:DAISLEY, SAMUEL J (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:DAISLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 E MAIN ST
Mailing Address - Street 2:BOX 1117
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-9479
Mailing Address - Country:US
Mailing Address - Phone:440-293-5555
Mailing Address - Fax:440-293-6643
Practice Address - Street 1:149 E MAIN ST
Practice Address - Street 2:BOX 1117
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003-9479
Practice Address - Country:US
Practice Address - Phone:440-293-5555
Practice Address - Fax:440-293-6643
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34004448207Q00000X
PAOS006385L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA092290OtherHIGHMARK BCBS- OH LOCATIO
OH0679930Medicaid
PA1760701OtherHIGHMARK BCBS- PA LOCATIO
OH000000137900OtherANTHEM BCBS
A17117Medicare UPIN
PA056711QGBMedicare ID - Type Unspecified
OH000000137900OtherANTHEM BCBS