Provider Demographics
NPI:1780738765
Name:PERKINS, SAMUEL E JR (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:E
Last Name:PERKINS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD.
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:1340 S 18TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4733
Practice Address - Country:US
Practice Address - Phone:904-277-3277
Practice Address - Fax:904-277-3611
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046209208600000X
FLME 98802208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL310129OtherAVMED
FL278432700Medicaid
FL7621418OtherAETNA
FL78270OtherBCBS
FL8997131OtherCIGNA
GA000960242AMedicaid
GA000960242AMedicaid
FL7621418OtherAETNA
020053374Medicare PIN
FL78270OtherBCBS