Provider Demographics
NPI:1265613509
Name:SRINIVAS SAMAK MD.PA
Entity type:Organization
Organization Name:SRINIVAS SAMAK MD.PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:SAMAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-688-3674
Mailing Address - Street 1:1500 LAKELAND HILLS BLVD
Mailing Address - Street 2:#4
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3257
Mailing Address - Country:US
Mailing Address - Phone:863-688-3674
Mailing Address - Fax:863-616-9902
Practice Address - Street 1:1500 LAKELAND HILLS BLVD
Practice Address - Street 2:#4
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3257
Practice Address - Country:US
Practice Address - Phone:863-688-3674
Practice Address - Fax:863-616-9902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SRINIVAS P.SAMAK.MD.PA.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8607Medicare PIN