Provider Demographics
NPI:1093813347
Name:SAMIMI, SAM A (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:A
Last Name:SAMIMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALLAHYAR
Other - Middle Name:G
Other - Last Name:SAMADAEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10004 KENNERLY ROAD
Mailing Address - Street 2:SUITE 210 ,BUILDING A..
Mailing Address - City:ST.LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:64128-5116
Mailing Address - Country:US
Mailing Address - Phone:314-842-3525
Mailing Address - Fax:314-842-3337
Practice Address - Street 1:1165 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1938
Practice Address - Country:US
Practice Address - Phone:714-991-9990
Practice Address - Fax:714-991-9496
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35768207N00000X
CAA38169207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202384400Medicaid