Provider Demographics
NPI:1629394390
Name:SAHA, SAM KUMAR
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:KUMAR
Last Name:SAHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9110 COLLEGE POINTE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3244
Mailing Address - Country:US
Mailing Address - Phone:239-560-4310
Mailing Address - Fax:239-208-3994
Practice Address - Street 1:315 MEDICAL PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1902
Practice Address - Country:US
Practice Address - Phone:704-403-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3383242084N0400X
MI43011171242084N0400X
OH35.1354962084N0400X
NY2988772084N0400X
ORMD1922462084N0400X
FLME1399422084N0400X
IL0361489152084N0400X
NH195432084N0400X
VA01012718402084N0400X
NC2013-018792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3119493Medicaid
SCNC2251Medicaid
NC1629394390Medicaid