Provider Demographics
NPI:1760743009
Name:SAMUELS, LA SHARON BOBO (MD)
Entity Type:Individual
Prefix:DR
First Name:LA SHARON
Middle Name:BOBO
Last Name:SAMUELS
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 1:64 MILL HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-1611
Mailing Address - Country:US
Mailing Address - Phone:313-506-0124
Mailing Address - Fax:
Practice Address - Street 1:4986 N ADAMS RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070962208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics