Provider Demographics
NPI:1306851704
Name:MISSAK, SAMIR SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMIR
Middle Name:SAMUEL
Last Name:MISSAK
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 1040
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-1040
Mailing Address - Country:US
Mailing Address - Phone:276-926-6258
Mailing Address - Fax:276-926-6222
Practice Address - Street 1:HOSPITAL DRIVE
Practice Address - Street 2:BUILDING 1
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-6258
Practice Address - Fax:276-926-6222
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046837207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E97179Medicare UPIN