Healthcare Provider Details

I. General information

NPI: 1366403255
Provider Name (Legal Business Name): SAM CARROLL WEST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HAVEN DR
DOTHAN AL
36301-2919
US

IV. Provider business mailing address

207 HAVEN DR
DOTHAN AL
36301-2919
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-1964
  • Fax: 334-794-4131
Mailing address:
  • Phone: 334-793-1964
  • Fax: 334-794-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8923
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: