Provider Demographics
NPI:1982661757
Name:WARD, SAMUEL EDWARD (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:EDWARD
Last Name:WARD
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 1:1409 BRICKYARD RD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-5967
Mailing Address - Country:US
Mailing Address - Phone:850-547-3679
Mailing Address - Fax:855-492-6785
Practice Address - Street 1:1409 BRICKYARD RD
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-5967
Practice Address - Country:US
Practice Address - Phone:850-547-3679
Practice Address - Fax:855-492-6785
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258988500Medicaid
FL35511OtherBLUE SHIELD
35511EMedicare ID - Type Unspecified
FL35511OtherBLUE SHIELD