Provider Demographics
NPI:1831300995
Name:AMEN, SAMUEL ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ALAN
Last Name:AMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 3RD AVE W STE 110
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8641
Mailing Address - Country:US
Mailing Address - Phone:941-708-9555
Mailing Address - Fax:941-708-5465
Practice Address - Street 1:100 3RD AVE W STE 110
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8641
Practice Address - Country:US
Practice Address - Phone:941-708-9555
Practice Address - Fax:941-708-5465
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23587207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200521770AMedicaid
OK200521770AMedicaid