Provider Demographics
NPI:1942385851
Name:OOMMEN, SAMUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:OOMMEN
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 1:1450 TREAT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-296-7340
Mailing Address - Fax:
Practice Address - Street 1:1479 YGNACIO VALLEY RD # 200
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-296-7340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43862208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29746Medicare UPIN
CA00A438620Medicare ID - Type Unspecified