Provider Demographics
NPI:1720287659
Name:SAMUEL, ABIE ALIAS (DO)
Entity Type:Individual
Prefix:DR
First Name:ABIE
Middle Name:ALIAS
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ABIE
Other - Middle Name:NELLATT
Other - Last Name:ALIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 12868
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-2868
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-8325
Practice Address - Fax:727-824-8347
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11459207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004276600Medicaid
FL004276600Medicaid