Provider Demographics
NPI:1124180054
Name:NANDIN, SAMUEL PONCE (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:PONCE
Last Name:NANDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13851 W LA MAR BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1389
Mailing Address - Country:US
Mailing Address - Phone:623-925-2622
Mailing Address - Fax:623-925-9260
Practice Address - Street 1:13851 W LA MAR BLVD
Practice Address - Street 2:STE C
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1389
Practice Address - Country:US
Practice Address - Phone:623-925-2622
Practice Address - Fax:623-925-9260
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ15582208D00000X
AZ15582207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106223600OtherOWCP
AZ562491245OtherAZ. FOUNDATION FOR MEDICA
AZ562491245OtherLIFE WISE HEALTHPLAN
AZ562491245OtherUNITEDHEALTH CARE
AZ562491245OtherSCF OF ARIZONA
AZAZ0766630OtherBCBS OF AZ
AZ562491245OtherHUMANA
AZ273607001OtherAHCCCS
AZ562491245OtherBEECHSTREET NETWORK
AZ2Z1748OtherHEALTH NET
AZ5008111OtherAETNA PROVIDER NO.
AZH73313Medicare UPIN
AZ562491245OtherLIFE WISE HEALTHPLAN