Healthcare Provider Details

I. General information

NPI: 1700909702
Provider Name (Legal Business Name): SAMUEL GRAY DEEM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE SUITE 602
CHARLESTON WV
25304-1223
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 602
CHARLESTON WV
25304-1231
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5120
  • Fax: 304-388-5125
Mailing address:
  • Phone: 304-388-5280
  • Fax: 304-388-5291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2176
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: