Healthcare Provider Details

I. General information

NPI: 1124609342
Provider Name (Legal Business Name): SANTROY ODANE SAMUELS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINELLAS ST # MS 70
CLEARWATER FL
33756-3804
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 727-462-3702
  • Fax: 727-298-6702
Mailing address:
  • Phone: 727-532-0002
  • Fax:

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 StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS22116
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: