Provider Demographics
NPI:1902917776
Name:BAVLI, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BAVLI
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 1:327 BEACH 19TH ST
Mailing Address - Street 2:DEPT. OF MEDICINE
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4423
Mailing Address - Country:US
Mailing Address - Phone:718-869-7315
Mailing Address - Fax:718-869-8530
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:718-869-7315
Practice Address - Fax:718-869-8530
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109310-1207RE0101X
NY109310207RH0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00887018Medicaid
NYB19712Medicare UPIN
NY6514TFMedicare PIN