Provider Demographics
NPI:1750347589
Name:MIETLING, SAMUEL W (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:W
Last Name:MIETLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1125 TROUPE ST
Mailing Address - Street 2:P.O. BOX 3129
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3129
Mailing Address - Country:US
Mailing Address - Phone:706-737-4575
Mailing Address - Fax:706-731-5289
Practice Address - Street 1:2416 DUNN AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-1015
Practice Address - Country:US
Practice Address - Phone:904-353-3664
Practice Address - Fax:904-353-3858
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0516862085B0100X, 2085D0003X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085U0001X, 2085R0204X
FLME493112085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00952795CMedicaid
GA00952795AMedicaid
GA00952795BMedicaid
1346357217OtherNPI - VASCULAR RADIOLOGY
SC83555OtherSC MEDICAL LICENSE
SCG51686Medicaid
GA30BDKLPMedicare PIN