Provider Demographics
NPI:1205939865
Name:SAMUEL, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:333 CEDAR STREET-LMP4085
Mailing Address - Street 2:P.O.BOX 208064 DEPARTMENT OF PEDIATRICS
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8064
Mailing Address - Country:US
Mailing Address - Phone:203-785-6668
Mailing Address - Fax:203-785-6925
Practice Address - Street 1:333 CEDAR STREET LMP4085
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520-8064
Practice Address - Country:US
Practice Address - Phone:203-785-6668
Practice Address - Fax:203-785-6925
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-05-11
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Provider Licenses
StateLicense IDTaxonomies
CT047046208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00575388Medicaid
NY00575388Medicaid
C09671Medicare UPIN