Provider Demographics
NPI:1427270370
Name:SAMUEL, MINI A (MBBS)
Entity type:Individual
Prefix:DR
First Name:MINI
Middle Name:A
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 STEVENS WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-364-3772
Mailing Address - Fax:
Practice Address - Street 1:1150 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUBGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000013497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine