Provider Demographics
NPI:1881655744
Name:FILICIOTTO, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:FILICIOTTO
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 1:15708 POMERADO RD
Mailing Address - Street 2:SUITE N-207
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2066
Mailing Address - Country:US
Mailing Address - Phone:858-487-8741
Mailing Address - Fax:
Practice Address - Street 1:15708 POMERADO RD
Practice Address - Street 2:SUITE N 207
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2066
Practice Address - Country:US
Practice Address - Phone:858-487-8741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65491208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G654911Medicaid
CAG65491Medicare PIN