1598791360 NPI number — DR. SAMANTHA LYNNE MULLIS MD

Table of content: DR. SAMANTHA LYNNE MULLIS MD (NPI 1598791360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598791360 NPI number — DR. SAMANTHA LYNNE MULLIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIS
Provider First Name:
SAMANTHA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MULLIS
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598791360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 NW 17TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-554-0893
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BETHESDA EAST HOSPITAL
Provider Second Line Business Practice Location Address:
2815 SEACREST BLVD
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-737-7733
Provider Business Practice Location Address Fax Number:
203-325-8677
Provider Enumeration Date:
06/24/2006

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: 207L00000X , with the licence number:  036211 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00781700 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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