Provider Demographics
NPI:1790977221
Name:SAMUEL, SMITHA (MD)
Entity Type:Individual
Prefix:
First Name:SMITHA
Middle Name:
Last Name:SAMUEL
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:PO BOX 19656
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9656
Mailing Address - Country:US
Mailing Address - Phone:217-545-8853
Mailing Address - Fax:217-545-0828
Practice Address - Street 1:3003 WAKEFIELD DR
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-2422
Practice Address - Country:US
Practice Address - Phone:708-747-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-052368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics