Provider Demographics
NPI:1578659173
Name:SAM, OLAI VIVIAN (MD)
Entity Type:Individual
Prefix:
First Name:OLAI
Middle Name:VIVIAN
Last Name:SAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 REMSEN STREET
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047
Mailing Address - Country:US
Mailing Address - Phone:518-235-7282
Mailing Address - Fax:518-235-4274
Practice Address - Street 1:95 REMSEN STREET
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047
Practice Address - Country:US
Practice Address - Phone:518-235-7282
Practice Address - Fax:518-235-4274
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G78576Medicare UPIN