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General NPI Number Information
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NPI Number | 1154588762
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Entity Type | Individual
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Provider Name | SAMUEL SELASIE MORTOTI MBCHB
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Gender | Male
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Dates
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Enumeration Date | 05/21/2008
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Last Update Date | 08/01/2013
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Provider Practice Location Address
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Address Line | 2000 MCLAIN ST SUITE H
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City | NEWPORT
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State | AR
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Zip | 72112-3661
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Country | US
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Telephone | 870-523-2404
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Fax |
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Provider Business Mailing Address
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Address Line | 5412 DEERFIELD DR
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City | JONESBORO
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State | AR
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Zip | 72404-8467
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Country | US
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Telephone | 202-290-4161
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | E-7981
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License Number State | AR
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