Provider Demographics
NPI:1194930180
Name:SAMUELSON, MELISSA (MD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MANNLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4219 WARNER ST
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-4059
Mailing Address - Country:US
Mailing Address - Phone:201-564-0245
Mailing Address - Fax:
Practice Address - Street 1:12220 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1608
Practice Address - Country:US
Practice Address - Phone:301-881-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054859208000000X
DCMD034502208000000X
VA0101235307208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics