Provider Demographics
NPI:1912964586
Name:RAWLS, SAMUEL T (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:RAWLS
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 1:7406 FULLERTON ST STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3588
Mailing Address - Country:US
Mailing Address - Phone:904-802-6800
Mailing Address - Fax:
Practice Address - Street 1:7406 FULLERTON ST STE 105
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3588
Practice Address - Country:US
Practice Address - Phone:904-802-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME139183207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000692898AMedicaid
GAC64750Medicare UPIN
GA000692898AMedicaid