Provider Demographics
NPI:1124609342
Name:SAMUELS, SANTROY ODANE (DO)
Entity type:Individual
Prefix:
First Name:SANTROY
Middle Name:ODANE
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20900 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1495
Mailing Address - Country:US
Mailing Address - Phone:305-692-3320
Mailing Address - Fax:
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-333-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program