Provider Demographics
NPI:1033503164
Name:WU, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WU
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 1:1072 XRAY DR
Mailing Address - Street 2:STE B
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:309 S SHARON AMITY RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2886
Practice Address - Country:US
Practice Address - Phone:704-344-8846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267259207N00000X
NC2020-01159207ZD0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology