Provider Demographics
NPI:1801899570
Name:DISMOND, SAMUEL III (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:DISMOND
Suffix:III
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 2238
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95473-2238
Mailing Address - Country:US
Mailing Address - Phone:415-800-7667
Mailing Address - Fax:831-622-8401
Practice Address - Street 1:436 14TH ST STE 1529
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2703
Practice Address - Country:US
Practice Address - Phone:510-727-5126
Practice Address - Fax:510-405-6147
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62220208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF16238Medicare UPIN
CA00G622200Medicare ID - Type Unspecified