Provider Demographics
NPI:1790005197
Name:SAMUELIAN, JASON MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:SAMUELIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14155 N 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5639
Mailing Address - Country:US
Mailing Address - Phone:623-773-2873
Mailing Address - Fax:623-414-4922
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5639
Practice Address - Country:US
Practice Address - Phone:623-773-2873
Practice Address - Fax:623-414-4922
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR1783207R00000X
AZ0066512085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine