Provider Demographics
NPI:1447562152
Name:AKIDIVA, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:AKIDIVA
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:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1358
Mailing Address - Country:US
Mailing Address - Phone:316-293-3429
Mailing Address - Fax:316-293-1882
Practice Address - Street 1:1010 N KANSAS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3124
Practice Address - Country:US
Practice Address - Phone:316-293-1840
Practice Address - Fax:316-293-1866
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine