Provider Demographics
NPI:1760587596
Name:ITSCOITZ, SAMUEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:ITSCOITZ
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 1:3100 WYMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12070 OLD LINE CTR STE 303
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3535
Practice Address - Country:US
Practice Address - Phone:301-645-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0005568207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0787143OtherAETNA
24324OtherMAMSI
MD206411100Medicaid
4086234OtherUNITED HEALTH CARE
KA62ITOtherBLUE CROSS MD
58030002OtherBLUE CROSS DC
MD779721400Medicaid
CM6438OtherRAILROAD MEDICARE
4086234OtherUNITED HEALTH CARE
408799Medicare ID - Type Unspecified