Provider Demographics
NPI:1740232727
Name:MICHAEL SAMKO, PH.D., INC.
Entity Type:Organization
Organization Name:MICHAEL SAMKO, PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SAMKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-721-1111
Mailing Address - Street 1:2181 S EL CAMINO REAL
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6220
Mailing Address - Country:US
Mailing Address - Phone:760-721-1111
Mailing Address - Fax:760-721-1116
Practice Address - Street 1:2181 S EL CAMINO REAL
Practice Address - Street 2:SUITE 201
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6220
Practice Address - Country:US
Practice Address - Phone:760-721-1111
Practice Address - Fax:760-721-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00203711OtherRAILROAD MEDICARE ID
CA00PL54200OtherBLUE SHIELD OF CALIFORNIA
CA00PL54200OtherBLUE SHIELD OF CALIFORNIA