Provider Demographics
NPI:1396736971
Name:SAM, ALBERT D II (MD)
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:D
Last Name:SAM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:DEVON
Other - Last Name:SAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:1800 N BEAUREGARD ST STE 50
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1735
Practice Address - Country:US
Practice Address - Phone:703-205-7330
Practice Address - Fax:703-205-7331
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15157R208600000X
CT556732086S0129X
VA01012682762086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1162604Medicaid
LAG57188Medicare UPIN