Provider Demographics
NPI:1528023264
Name:SANNOUFI, SAMER S (MD)
Entity Type:Individual
Prefix:
First Name:SAMER
Middle Name:S
Last Name:SANNOUFI
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 1:6900 BROCKTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3818
Mailing Address - Country:US
Mailing Address - Phone:951-682-6263
Mailing Address - Fax:951-682-0114
Practice Address - Street 1:6900 BROCKTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-682-6263
Practice Address - Fax:951-682-0114
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD33024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC53604OtherCALIFORNIA MEDICAL BOARD
I02454Medicare UPIN