Provider Demographics
NPI:1407946825
Name:SAMPER, LUIS (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:SAMPER
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 1:750 NORTH COBB STREET
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061
Mailing Address - Country:US
Mailing Address - Phone:478-453-9383
Mailing Address - Fax:478-452-1147
Practice Address - Street 1:750 NORTH COBB STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061
Practice Address - Country:US
Practice Address - Phone:478-453-9383
Practice Address - Fax:478-452-1147
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13713208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0011822AMedicaid
GA52041050002OtherBCBS
GA52041050002OtherBCBS