Provider Demographics
NPI:1427430370
Name:GILES, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 THE GREENS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1422
Mailing Address - Country:US
Mailing Address - Phone:904-800-7380
Mailing Address - Fax:904-467-8932
Practice Address - Street 1:1680 THE GREENS WAY STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-1422
Practice Address - Country:US
Practice Address - Phone:904-800-7380
Practice Address - Fax:904-467-8932
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264120207R00000X
FLME1404492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103365500Medicaid