Provider Demographics
NPI:1720468408
Name:MASTER, SAMUEL (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MASTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 WEST 168TH ST
Mailing Address - Street 2:VC 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-342-3200
Mailing Address - Fax:212-342-4733
Practice Address - Street 1:622 WEST 168TH ST
Practice Address - Street 2:VC4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-342-3233
Practice Address - Fax:212-342-4733
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016663208000000X
NY294447208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22-2540851Medicaid