Provider Demographics
NPI:1699816322
Name:SENCIL, SAMUEL KAZUE (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KAZUE
Last Name:SENCIL
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:706-788-2936
Practice Address - Street 1:206 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:GA
Practice Address - Zip Code:30624-2109
Practice Address - Country:US
Practice Address - Phone:706-245-7361
Practice Address - Fax:706-245-4054
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055971207R00000X
MDH000642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG40659Medicare UPIN
MD603QMedicare ID - Type Unspecified
SCG55971Medicaid