Provider Demographics
NPI:1821153677
Name:PERSAD, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:PERSAD
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 1:730 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134-1332
Mailing Address - Country:US
Mailing Address - Phone:270-586-7053
Mailing Address - Fax:
Practice Address - Street 1:730 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-1332
Practice Address - Country:US
Practice Address - Phone:270-586-7053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18333208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64183338Medicaid
1067101Medicare ID - Type Unspecified
KY64183338Medicaid