Provider Demographics
NPI:1699745042
Name:GARRETT, SAMUEL N (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:N
Last Name:GARRETT
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 1:465 N GREAT NECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4064
Mailing Address - Country:US
Mailing Address - Phone:757-481-5555
Mailing Address - Fax:757-481-6486
Practice Address - Street 1:465 N GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4064
Practice Address - Country:US
Practice Address - Phone:757-481-5555
Practice Address - Fax:757-481-6486
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6301568Medicaid
E45767Medicare UPIN
VA6301568Medicaid