Provider Demographics
NPI:1679513477
Name:SAMARA, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:SAMARA
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 1:6555 CHESTER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2279
Mailing Address - Country:US
Mailing Address - Phone:904-309-6504
Mailing Address - Fax:904-503-3577
Practice Address - Street 1:6555 CHESTER AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2279
Practice Address - Country:US
Practice Address - Phone:904-309-6504
Practice Address - Fax:904-503-3577
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31637207QG0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15431OtherBLUE SHIELD
340017155OtherRAILROAD MEDICARE
FL059539000Medicaid
FLME31637OtherMEDICAL LIC
340017155OtherRAILROAD MEDICARE
FLME31637OtherMEDICAL LIC