Healthcare Provider Details

I. General information

NPI: 1043742695
Provider Name (Legal Business Name): SAMUEL JUSTIN SPIEGEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S FAIR OAKS AVE STE 280
PASADENA CA
91105-2670
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 626-817-4747
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax: 650-498-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberA159963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: