Provider Demographics
NPI:1154588762
Name:MORTOTI, SAMUEL SELASIE (MBCHB)
Entity type:Individual
Prefix:DR
First Name:SAMUEL SELASIE
Middle Name:
Last Name:MORTOTI
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8467
Mailing Address - Country:US
Mailing Address - Phone:202-290-4161
Mailing Address - Fax:
Practice Address - Street 1:2000 MCLAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3661
Practice Address - Country:US
Practice Address - Phone:870-523-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7981207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease