Provider Demographics
NPI:1376838243
Name:SAMUEL, BANKOLE A (MD)
Entity type:Individual
Prefix:
First Name:BANKOLE
Middle Name:A
Last Name:SAMUEL
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 1:85 LINCOLN STREET
Mailing Address - Street 2:410
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702
Mailing Address - Country:US
Mailing Address - Phone:508-820-1650
Mailing Address - Fax:508-872-2796
Practice Address - Street 1:85 LINCOLN STREET
Practice Address - Street 2:410
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702
Practice Address - Country:US
Practice Address - Phone:508-820-1650
Practice Address - Fax:508-872-2796
Is Sole Proprietor?:No
Enumeration Date:2011-06-18
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA270942208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099405AMedicaid