Provider Demographics
NPI:1942394366
Name:TEFERRA, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:TEFERRA
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:1942 E 7TH ST STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2418
Practice Address - Country:US
Practice Address - Phone:704-384-7085
Practice Address - Fax:704-384-7089
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-1841207Q00000X
NC2018-02891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2021663Medicaid
MO1942394366Medicaid
OH196962OtherANTHEM BCBS OF OHIO
KS200605710AMedicaid
MOP00651330Medicare PIN
MO1942394366Medicaid
OH2021663Medicaid
OH196962OtherANTHEM BCBS OF OHIO