Healthcare Provider Details

I. General information

NPI: 1235366899
Provider Name (Legal Business Name): SAMUEL JOSEPH KUZMINSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WAKE FOREST RD
RALEIGH NC
27609-7317
US

IV. Provider business mailing address

2613 ROCK OAK CT
RALEIGH NC
27613-6255
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5003
  • Fax: 919-660-9277
Mailing address:
  • Phone: 405-830-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number27058
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2013-01755
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: