Provider Demographics
NPI:1275622987
Name:MARCO, SAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:MARCO
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 1:7008 SW ANGELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9641
Mailing Address - Country:US
Mailing Address - Phone:817-733-4304
Mailing Address - Fax:
Practice Address - Street 1:901 SW GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9755
Practice Address - Country:US
Practice Address - Phone:580-510-6384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine