Provider Demographics
NPI:1417075466
Name:SAZAMA, RICHARD CLINE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLINE
Last Name:SAZAMA
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 1:405 S CLARK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3065
Mailing Address - Country:US
Mailing Address - Phone:712-792-2222
Mailing Address - Fax:
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-792-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23686208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30412100Medicaid
WI007120270Medicare PIN
WI30412100Medicaid