Healthcare Provider Details

I. General information

NPI: 1013094341
Provider Name (Legal Business Name): SAMUEL LEE DRAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 WILSHIRE BLVD SUITE 714
LOS ANGELES CA
90010-2307
US

IV. Provider business mailing address

3540 WILSHIRE BLVD SUITE 714
LOS ANGELES CA
90010-2307
US

V. Phone/Fax

Practice location:
  • Phone: 213-382-2063
  • Fax: 213-382-4935
Mailing address:
  • Phone: 213-382-2063
  • Fax: 213-382-4935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberC37664
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC37664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: