Provider Demographics
NPI:1265514442
Name:SAMPLE, GEORGE A (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:SAMPLE
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 1:1201 SEVEN LOCKS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2931
Mailing Address - Country:US
Mailing Address - Phone:301-652-5771
Mailing Address - Fax:301-652-6332
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:RM 4B42
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-7259
Practice Address - Fax:202-877-7258
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD17192207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD282871700Medicaid
VA6002331Medicaid
DC026108100Medicaid
VA6002331Medicaid