Provider Demographics
NPI:1063744530
Name:SAMUEL W. KAUFMAN, M.D., INC.
Entity type:Organization
Organization Name:SAMUEL W. KAUFMAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VRIEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-946-2801
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-0996
Mailing Address - Country:US
Mailing Address - Phone:909-946-2801
Mailing Address - Fax:909-946-3247
Practice Address - Street 1:4515 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-3102
Practice Address - Country:US
Practice Address - Phone:909-946-2801
Practice Address - Fax:909-946-3247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA284262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25356Medicare UPIN