Provider Demographics
NPI:1023254521
Name:SAMUELS, JONATHAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 CEDARHURST DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2026
Mailing Address - Country:US
Mailing Address - Phone:248-470-2348
Mailing Address - Fax:248-668-9222
Practice Address - Street 1:5111 CEDARHURST DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2026
Practice Address - Country:US
Practice Address - Phone:248-470-2348
Practice Address - Fax:248-668-9222
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061842207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG37025Medicare UPIN