Provider Demographics
NPI:1548780323
Name:SAM, STEPHANIE (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-4011
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74020-21207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine