Provider Demographics
NPI:1740365154
Name:SAMUELLY, MICHAELA (MD)
Entity type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:
Last Name:SAMUELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2706
Mailing Address - Country:US
Mailing Address - Phone:718-693-0341
Mailing Address - Fax:
Practice Address - Street 1:928 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2706
Practice Address - Country:US
Practice Address - Phone:718-462-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC39692084P0800X
NY1102422084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00196814Medicaid
301941Medicare ID - Type Unspecified
NY00196814Medicaid