Provider Demographics
NPI:1386190569
Name:NIMO, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:NIMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8213 NW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-4811
Mailing Address - Country:US
Mailing Address - Phone:405-474-6466
Mailing Address - Fax:
Practice Address - Street 1:9210 S WESTERN AVE STE A-21
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139
Practice Address - Country:US
Practice Address - Phone:405-703-8755
Practice Address - Fax:405-895-7544
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist