Provider Demographics
NPI:1104990472
Name:SAMUEL, GONNA (MD)
Entity type:Individual
Prefix:
First Name:GONNA
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 1:958 DOWNING RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1509
Mailing Address - Country:US
Mailing Address - Phone:917-302-8478
Mailing Address - Fax:
Practice Address - Street 1:5314 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3609
Practice Address - Country:US
Practice Address - Phone:718-240-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11019001500Medicaid
NYG66737Medicare UPIN
NY334281Medicare ID - Type Unspecified