Provider Demographics
NPI:1578553335
Name:KOKORIS, SAM PETER (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:PETER
Last Name:KOKORIS
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 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:1530 BESSIE AVE
Practice Address - Street 2:STE 108
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG815192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G815190OtherBLUE SHIELD
CA00G815190Medicaid
CA00G815191Medicare PIN
CA00G815195Medicare PIN
CA00G815194Medicare PIN
CA00G815196Medicare PIN
CA00G815193Medicare PIN
CA00G815190OtherBLUE SHIELD
CA00G815190Medicare PIN