Provider Demographics
NPI:1649324682
Name:SAMUEL, VINNY (MD)
Entity type:Individual
Prefix:
First Name:VINNY
Middle Name:
Last Name:SAMUEL
Suffix:
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 1:2639 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-2733
Mailing Address - Country:US
Mailing Address - Phone:727-822-6661
Mailing Address - Fax:727-823-1334
Practice Address - Street 1:2639 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-2733
Practice Address - Country:US
Practice Address - Phone:727-822-6661
Practice Address - Fax:727-823-1334
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105292207RP1001X, 207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGC363ZOtherMEDICARE PTAN
FL004762200Medicaid
FLP01081066OtherRAILROAD MEDICARE