Provider Demographics
NPI:1285787739
Name:SAMUEL, VIJAY (MD)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
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:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48303-1038
Mailing Address - Country:US
Mailing Address - Phone:247-347-8293
Mailing Address - Fax:
Practice Address - Street 1:44000 W 12 MILE RD.
Practice Address - Street 2:STE 213
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3111
Practice Address - Country:US
Practice Address - Phone:248-347-8293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010601702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4477679Medicaid
MI4477679Medicaid
MIG55355Medicare UPIN