Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | C37664 | CA |
NPI | 1013094341 |
---|---|
Provider Name | Dr. Samuel Lee Drake |
First Address | Los Angeles, CA 90010-2307 |
Second Address | Los Angeles, CA 90010-2307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 11/05/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BD8768129 | DEA NUMBER (01) | CA |
C37664 | MEDICAL LICENSE (01) | CA |