Healthcare Provider Details

I. General information

NPI: 1669497434
Provider Name (Legal Business Name): SAMSON TULU TEKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 15TH ST STE 2000
HUNTINGTON WV
25701-3662
US

IV. Provider business mailing address

1249 15TH ST STE 2000
HUNTINGTON WV
25701-3662
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1000
  • Fax: 304-691-1063
Mailing address:
  • Phone: 304-691-1000
  • Fax: 304-691-1063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4894128-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23621
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: