Provider Demographics
NPI:1306069380
Name:SAMUELS, WINSTON L (MD)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:L
Last Name:SAMUELS
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 1:1846 OLD NORCROSS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8801
Mailing Address - Country:US
Mailing Address - Phone:404-738-7878
Mailing Address - Fax:770-736-7134
Practice Address - Street 1:1846 OLD NORCROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8801
Practice Address - Country:US
Practice Address - Phone:404-738-7878
Practice Address - Fax:404-999-4968
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060867208D00000X
GA60867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA492804824LMedicaid