Provider Demographics
NPI:1689434417
Name:SAUCEDO, SAMUEL THOMAS
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:THOMAS
Last Name:SAUCEDO
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 1:155 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2302
Mailing Address - Country:US
Mailing Address - Phone:559-459-4004
Mailing Address - Fax:
Practice Address - Street 1:155 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2302
Practice Address - Country:US
Practice Address - Phone:559-459-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty