Provider Demographics
NPI:1780023267
Name:SHERIDAN, SAMUEL DAVID
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:SHERIDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4235
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-4235
Mailing Address - Country:US
Mailing Address - Phone:707-994-7090
Mailing Address - Fax:707-994-7092
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8131
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7092
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator