Provider Demographics
NPI:1073587382
Name:SHIMAMOTO, SAM REED (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:REED
Last Name:SHIMAMOTO
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 1:4915 E BASELINE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2966
Mailing Address - Country:US
Mailing Address - Phone:480-626-6600
Mailing Address - Fax:480-626-6604
Practice Address - Street 1:4915 E BASELINE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2965
Practice Address - Country:US
Practice Address - Phone:480-626-6600
Practice Address - Fax:480-626-6604
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29558207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104312Medicare PIN
AZH65616Medicare UPIN