Provider Demographics
NPI:1245687862
Name:SAMUEL, IRENE (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:VARGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:903 WORMWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2220 E LEAGUE CITY PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2100
Practice Address - Country:US
Practice Address - Phone:281-523-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU6796207Q00000X
WAML60661168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine