Provider Demographics
NPI:1679943278
Name:SAMUELS, TAMAR L (RDN)
Entity Type:Individual
Prefix:
First Name:TAMAR
Middle Name:L
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GRAND AVE
Mailing Address - Street 2:APT 1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2167
Mailing Address - Country:US
Mailing Address - Phone:917-705-9839
Mailing Address - Fax:
Practice Address - Street 1:149 MADISON AVE
Practice Address - Street 2:SUITE 1121
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6713
Practice Address - Country:US
Practice Address - Phone:347-831-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered