Healthcare Provider Details

I. General information

NPI: 1285631796
Provider Name (Legal Business Name): SAMUEL D VERNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 TERRACE DR
MARION VA
24354-4138
US

IV. Provider business mailing address

1070 TERRACE DR
MARION VA
24354-4138
US

V. Phone/Fax

Practice location:
  • Phone: 276-781-2225
  • Fax: 276-783-8843
Mailing address:
  • Phone: 276-781-2225
  • Fax: 276-783-8843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101025422
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: