Provider Demographics
NPI:1295730299
Name:SAMUEL, PRINCE D (MD)
Entity type:Individual
Prefix:DR
First Name:PRINCE
Middle Name:D
Last Name:SAMUEL
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 1:4221 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0675
Mailing Address - Country:US
Mailing Address - Phone:812-476-6500
Mailing Address - Fax:812-476-6507
Practice Address - Street 1:4221 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0675
Practice Address - Country:US
Practice Address - Phone:812-476-6500
Practice Address - Fax:812-476-6507
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057972A207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200454280Medicaid
INH72575Medicare UPIN
IN200454280Medicaid