Healthcare Provider Details

I. General information

NPI: 1801899570
Provider Name (Legal Business Name): SAMUEL DISMOND III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 14TH ST STE 1529
OAKLAND CA
94612-2703
US

IV. Provider business mailing address

PO BOX 2238
SEBASTOPOL CA
95473-2238
US

V. Phone/Fax

Practice location:
  • Phone: 510-727-5126
  • Fax: 510-405-6147
Mailing address:
  • Phone: 415-800-7667
  • Fax: 831-622-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG62220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: