Provider Demographics
NPI:1265431415
Name:NEELEY, SAMUEL R (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:NEELEY
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 1:12446 WEST AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2530
Mailing Address - Country:US
Mailing Address - Phone:210-525-1668
Mailing Address - Fax:
Practice Address - Street 1:12446 WEST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2517
Practice Address - Country:US
Practice Address - Phone:210-525-1668
Practice Address - Fax:210-525-1669
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2016-10-19
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TXE8757204D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120344004Medicaid
TX120344004Medicaid
TXTXB145650Medicare PIN
TX00HB03Medicare ID - Type Unspecified