Provider Demographics
NPI:1356580567
Name:JACOB A SAMANDER MD PA
Entity type:Organization
Organization Name:JACOB A SAMANDER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAMANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-905-8531
Mailing Address - Street 1:PO BOX 882076
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-2076
Mailing Address - Country:US
Mailing Address - Phone:772-905-8531
Mailing Address - Fax:772-905-8526
Practice Address - Street 1:1401 SE GOLDTREE DR
Practice Address - Street 2:STE 104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7584
Practice Address - Country:US
Practice Address - Phone:772-905-8531
Practice Address - Fax:772-905-8526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00633392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG11395Medicare UPIN