Provider Demographics
NPI:1346213220
Name:SAMPSON, LORENZO KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:LORENZO
Middle Name:KEITH
Last Name:SAMPSON
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 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-648-1318
Mailing Address - Fax:
Practice Address - Street 1:410 UNIVERSITY PKWY STE 2310
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6835
Practice Address - Country:US
Practice Address - Phone:803-648-1318
Practice Address - Fax:803-642-7803
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8468208600000X
SC26694208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145641002Medicaid
SC266946Medicaid
TX8H8817OtherBCBS
TX145641002Medicaid
TX8G3391Medicare PIN