Provider Demographics
NPI:1790811610
Name:KAUFMAN, SAMUEL W (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:KAUFMAN
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:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-0996
Mailing Address - Country:US
Mailing Address - Phone:909-920-1049
Mailing Address - Fax:909-946-3247
Practice Address - Street 1:825 TRINITY LN
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2957
Practice Address - Country:US
Practice Address - Phone:909-946-2801
Practice Address - Fax:909-946-3247
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA284262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A284260Medicaid
CA00A284260Medicare ID - Type UnspecifiedNO CALIF MCARE
CA00A284260Medicaid
CAA25356Medicare UPIN