Healthcare Provider Details

I. General information

NPI: 1033805130
Provider Name (Legal Business Name): SAMUEL MEMMELAAR DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 LK UNDER HL
ORLANDO FL
32822-8224
US

IV. Provider business mailing address

8310 100TH ST SE
ALTO MI
49302-9628
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-8110
  • Fax:
Mailing address:
  • Phone: 616-540-1837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: