Provider Demographics
NPI:1437544780
Name:DOVGAN, SAMO JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMO
Middle Name:JACOB
Last Name:DOVGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMO
Other - Middle Name:JAKOB
Other - Last Name:DOVGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 7610
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6198
Mailing Address - Country:US
Mailing Address - Phone:719-547-8796
Mailing Address - Fax:
Practice Address - Street 1:1173 S LOS CHARROS DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-6198
Practice Address - Country:US
Practice Address - Phone:719-547-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00153182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology