Provider Demographics
NPI:1285639203
Name:SAM, MIRELA (MD)
Entity type:Individual
Prefix:
First Name:MIRELA
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1122
Mailing Address - Country:US
Mailing Address - Phone:718-484-3954
Mailing Address - Fax:718-484-3955
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-484-3954
Practice Address - Fax:718-484-3955
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY198399207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01587686Medicaid
NY01587686Medicaid
00N011Medicare PIN