MEDICARE: DR. SAMUEL DISMOND III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	G62220	CA

General Provider Information

NPI Number	:	1801899570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL DISMOND III M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2238
Second Line	:
City	:	SEBASTOPOL
State	:	CA
Zip	:	95473-2238
Country	:	US
Telephone Number	:	415-800-7667
Fax Number	:	831-622-8401

Provider Business Practice Location Address
First Line	:	436 14TH ST STE 1529
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94612-2703
Country	:	US
Telephone Number	:	510-727-5126
Fax Number	:	510-405-6147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	04/09/2022

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