Provider Demographics
NPI:1376600973
Name:DOCENA, SAMUEL CHICANO (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:CHICANO
Last Name:DOCENA
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 1:1244 NILLES RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2786
Mailing Address - Country:US
Mailing Address - Phone:513-858-6110
Mailing Address - Fax:
Practice Address - Street 1:1244 NILLES RD
Practice Address - Street 2:SUITE 10
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2786
Practice Address - Country:US
Practice Address - Phone:513-858-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH49019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739473Medicaid
OHSA0884241Medicare ID - Type Unspecified
OH0739473Medicaid