Provider Demographics
NPI:1215991856
Name:CHACON, SAMUEL R (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:CHACON
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 1:540 W PLUMB LN STE 200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3683
Mailing Address - Country:US
Mailing Address - Phone:775-870-1521
Mailing Address - Fax:775-870-1892
Practice Address - Street 1:540 W PLUMB LN STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3683
Practice Address - Country:US
Practice Address - Phone:775-870-1521
Practice Address - Fax:775-870-1892
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9105207VF0040X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002013064Medicaid
NVGC986ZMedicare PIN
NVG94264Medicare UPIN