Provider Demographics
NPI:1780063644
Name:HERMAN, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26671 ALISO CREEK RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4810
Mailing Address - Country:US
Mailing Address - Phone:949-791-3104
Mailing Address - Fax:949-791-3181
Practice Address - Street 1:26671 ALISO CREEK RD STE 206
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4810
Practice Address - Country:US
Practice Address - Phone:949-791-3104
Practice Address - Fax:949-791-3181
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
CODR.0068313207R00000X
CA178008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOOOMedicare UPIN
VAD0000Medicare UPIN