Provider Demographics
NPI:1144278094
Name:MALLER, SAMUEL G (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:MALLER
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:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-0709
Mailing Address - Country:US
Mailing Address - Phone:301-598-1590
Mailing Address - Fax:301-598-1596
Practice Address - Street 1:9701 VEIRS DR
Practice Address - Street 2:NATIONAL LUTHERAN HOME
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-424-9560
Practice Address - Fax:301-251-5279
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD278002000Medicaid
MD970040400Medicaid
DC490827Medicare ID - Type Unspecified
MDG57892Medicare UPIN
MD179441Medicare ID - Type Unspecified