1053784314 NPI number — MR. SAMMIE O'NEAL III MA, CDC1

Table of content: MR. SAMMIE O'NEAL III MA, CDC1 (NPI 1053784314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053784314 NPI number — MR. SAMMIE O'NEAL III MA, CDC1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'NEAL
Provider First Name:
SAMMIE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MA, CDC1
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053784314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12518 CRESTED BUTTE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE RIVER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99577-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-406-3033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12518 CRESTED BUTTE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE RIVER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99577-7654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-406-3033
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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