Provider Demographics
NPI:1689870990
Name:SAFAVI-ABBASI, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SAFAVI-ABBASI
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 1:1300 N RIM DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3143
Mailing Address - Country:US
Mailing Address - Phone:928-226-7667
Mailing Address - Fax:928-226-7664
Practice Address - Street 1:1300 N RIM DR STE A
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3143
Practice Address - Country:US
Practice Address - Phone:928-226-7667
Practice Address - Fax:928-226-7664
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49003207T00000X, 207T00000X
OK25808207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ907411Medicaid
AZZ166194Medicare PIN