Provider Demographics
NPI:1407030604
Name:SAMPSON, RICHARD B (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
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 1:127 E MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2288
Mailing Address - Country:US
Mailing Address - Phone:801-766-9822
Mailing Address - Fax:801-766-9441
Practice Address - Street 1:127 E MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2288
Practice Address - Country:US
Practice Address - Phone:801-766-9822
Practice Address - Fax:801-766-9441
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5003175-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1407030604Medicaid
UT1407030604Medicaid