Provider Demographics
NPI:1346336807
Name:SAMPLE, SALLY A (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 BIANCO COURT
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:916-925-7010
Mailing Address - Fax:
Practice Address - Street 1:3841 N FREEWAY BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1948
Practice Address - Country:US
Practice Address - Phone:916-925-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85941207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90118919OtherPACIFICARE
CA1741911OtherFIRST HEALTH
CAMCMG171600OtherWESTERN HEALTH ADVANTAGE
CA082689OtherHEALTH NET
CA1327116OtherUNITED HEALTHCARE
CA4594534OtherAETNA
CAG85941OtherBLUE CROSS
CA46355OtherINTERPLAN
CA000810342662OtherPHCS
CA1851073OtherGREAT WEST
CA3273994OtherCIGNA
CA082689OtherHEALTH NET
CA1741911OtherFIRST HEALTH