Provider Demographics
NPI:1710270426
Name:SAMUELSON, HEATHER MARIE (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:SAMUELSON
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 1:700 8TH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4737
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:
Practice Address - Street 1:302 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-272-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124557208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics