Provider Demographics
NPI:1063984094
Name:CARTER, SAMUEL D
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:D
Last Name:CARTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17433 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2339
Mailing Address - Country:US
Mailing Address - Phone:313-587-0949
Mailing Address - Fax:
Practice Address - Street 1:17433 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2339
Practice Address - Country:US
Practice Address - Phone:313-587-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280046208D00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice