Provider Demographics
NPI:1396904165
Name:SAMKO, MICHAEL R (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:SAMKO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 GLENMONT DR
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1308
Mailing Address - Country:US
Mailing Address - Phone:760-721-1111
Mailing Address - Fax:858-481-9791
Practice Address - Street 1:2125 S EL CAMINO REAL
Practice Address - Street 2:STE 206
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6260
Practice Address - Country:US
Practice Address - Phone:760-721-1111
Practice Address - Fax:858-481-9791
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200505235OtherTRICARE
CA00PL54200OtherBLUE SHIELD OF CALIFORNIA
CA200505235OtherBLUE CROSS OF CALIFORNIA
CAWCP5420AMedicare PIN