Provider Demographics
NPI:1790839496
Name:IM, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:IM
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 4316
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-4316
Mailing Address - Country:US
Mailing Address - Phone:562-900-1012
Mailing Address - Fax:562-789-4440
Practice Address - Street 1:12462 PUTNAM ST
Practice Address - Street 2:SUITE 303
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1048
Practice Address - Country:US
Practice Address - Phone:562-900-1012
Practice Address - Fax:562-789-4440
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71341207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH49953Medicare UPIN
CAWA71341GMedicare ID - Type UnspecifiedPPIN
CAWA71341FMedicare ID - Type UnspecifiedPPIN