Provider Demographics
NPI:1336231539
Name:DICAPUA, SAMUEL M (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:DICAPUA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7452
Mailing Address - Country:US
Mailing Address - Phone:207-281-2720
Mailing Address - Fax:
Practice Address - Street 1:92 8TH ST
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7452
Practice Address - Country:US
Practice Address - Phone:207-281-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19852207Q00000X
ME1303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100009224OtherGROUP TAX ID#
ME1174615371OtherGROUP NPI#
ME005725OtherANTHEM
ME431784599Medicaid
MEE69122Medicare UPIN
ME100009224OtherGROUP TAX ID#