Provider Demographics
NPI:1871057554
Name:SAMUELS, DORINDA CONNIE X (MD)
Entity type:Individual
Prefix:
First Name:DORINDA
Middle Name:CONNIE
Last Name:SAMUELS
Suffix:X
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2302
Mailing Address - Country:US
Mailing Address - Phone:347-792-5794
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:7516 97TH AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-1024
Practice Address - Country:US
Practice Address - Phone:646-508-3274
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000000000000000104100000X
NYX12104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000000000Medicaid