Provider Demographics
NPI:1689477721
Name:DOTY, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DOTY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19121 NOTTINGHAM RD APT 301
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2773
Mailing Address - Country:US
Mailing Address - Phone:216-396-9480
Mailing Address - Fax:
Practice Address - Street 1:1303 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-450-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program