Healthcare Provider Details

I. General information

NPI: 1720468408
Provider Name (Legal Business Name): SAMUEL MASTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 WEST 168TH ST VC4
NEW YORK NY
10032
US

IV. Provider business mailing address

622 WEST 168TH ST VC 4
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-342-3233
  • Fax: 212-342-4733
Mailing address:
  • Phone: 212-342-3200
  • Fax: 212-342-4733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOT016663
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number294447
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number294447
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: