Provider Demographics
NPI:1700191046
Name:SAM, LIZBETH (MD)
Entity Type:Individual
Prefix:
First Name:LIZBETH
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2590 HEALING WAY STE 310
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5497
Mailing Address - Country:US
Mailing Address - Phone:703-795-8262
Mailing Address - Fax:
Practice Address - Street 1:2590 HEALING WAY STE 310
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5497
Practice Address - Country:US
Practice Address - Phone:813-333-1186
Practice Address - Fax:844-691-5928
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260376207T00000X
MDLC2261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional