Provider Demographics
NPI:1891826202
Name:UMESEGHA, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:UMESEGHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8402
Mailing Address - Country:US
Mailing Address - Phone:540-656-2950
Mailing Address - Fax:540-656-2957
Practice Address - Street 1:611 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8402
Practice Address - Country:US
Practice Address - Phone:540-656-2950
Practice Address - Fax:540-656-2957
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241718207R00000X, 207RG0300X
VA0101242169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02861067Medicaid
5DD1FEX661Medicare PIN
PENDINGMedicare UPIN
NY02861067Medicaid