=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174194955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ANTHONY MINAKER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2021
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 W GRANDE BLVD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75703-6124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-597-4644
-----------------------------------------------------
Fax | 903-266-9449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4539 CASCADES SHORELINE DR
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75709-8902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-590-9184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | V9664
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036155679
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | 036.155679
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | V9664
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------