Provider Demographics
NPI:1679502405
Name:SAMUELSON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SAMUELSON
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 1:56 NEW DRIFTWAY STE 301
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-4533
Mailing Address - Country:US
Mailing Address - Phone:781-544-1388
Mailing Address - Fax:781-544-3396
Practice Address - Street 1:56 NEW DRIFTWAY
Practice Address - Street 2:SUITE 301
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066
Practice Address - Country:US
Practice Address - Phone:781-544-1388
Practice Address - Fax:781-544-3396
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ22693OtherBCBS
MA710838OtherHARVARD PILGRAM
04099589OtherEVERCARE
1679502405OtherBCBS
MASX4210Medicare PIN
MAJ22693OtherBCBS
A31373Medicare PIN
1679502405OtherBCBS
P0033298Medicare PIN