Provider Demographics
NPI:1629047980
Name:SANDBERG, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SANDBERG
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 1:1520 W 53RD ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-2440
Mailing Address - Country:US
Mailing Address - Phone:563-421-3800
Mailing Address - Fax:563-421-3810
Practice Address - Street 1:1520 W 53RD ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2440
Practice Address - Country:US
Practice Address - Phone:563-421-3800
Practice Address - Fax:563-421-3810
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1184432Medicaid
IAI5098Medicare ID - Type Unspecified
IA1184432Medicaid