Healthcare Provider Details

I. General information

NPI: 1720323348
Provider Name (Legal Business Name): SAMUEL TAHK M.D., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 HC BDAACH UNIT 15245
APO GYEONGGI
96271
KR

IV. Provider business mailing address

BLDG 390 N. LOOP ROAD
FORT IRWIN CA
92310
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-2019
  • Fax:
Mailing address:
  • Phone: 866-957-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA139425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: