Provider Demographics
NPI:1417008004
Name:SAMPSON, BRUCE DUWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DUWAYNE
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 1:1019 KEITH DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069
Mailing Address - Country:US
Mailing Address - Phone:478-987-2556
Mailing Address - Fax:478-987-3137
Practice Address - Street 1:1019 KEITH DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069
Practice Address - Country:US
Practice Address - Phone:478-987-2556
Practice Address - Fax:478-987-3137
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21276207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3158Medicare ID - Type Unspecified
D30696Medicare UPIN