Provider Demographics
NPI:1760579171
Name:SAMUEL, DEVPRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:DEVPRAKASH
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 KRAFFT RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3821
Mailing Address - Country:US
Mailing Address - Phone:810-385-7700
Mailing Address - Fax:810-385-7760
Practice Address - Street 1:3050 KRAFFT RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3821
Practice Address - Country:US
Practice Address - Phone:810-385-7700
Practice Address - Fax:810-385-7760
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010550102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1307401332OtherBLUE CROSS BLUE SHIELD
MI3385090Medicaid
MI3385090Medicaid