Provider Demographics
NPI:1336187947
Name:WAITS, SAMUEL JACOB JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JACOB
Last Name:WAITS
Suffix:JR
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 1:208 MCFARLAND CIR N
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-1800
Mailing Address - Country:US
Mailing Address - Phone:205-345-7000
Mailing Address - Fax:205-758-3906
Practice Address - Street 1:208 MCFARLAND CIR N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406
Practice Address - Country:US
Practice Address - Phone:205-345-7000
Practice Address - Fax:205-758-3906
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS154582085R0202X
AL255682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124360Medicaid
AL009917105Medicaid
MS300138237OtherRAILROAD MEDICARE
MS300001105Medicare PIN
MS300138237OtherRAILROAD MEDICARE
MSH04736Medicare UPIN
AL051557180Medicare PIN
MS300000810Medicare PIN