Provider Demographics
NPI:1265938963
Name:SULTAN, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SULTAN
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 1:311 PROFESSIONAL PARK DR APT B
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3472
Mailing Address - Country:US
Mailing Address - Phone:715-559-8886
Mailing Address - Fax:
Practice Address - Street 1:443 SPRING ST STE 200
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4494
Practice Address - Country:US
Practice Address - Phone:715-559-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59070207Q00000X, 207Q00000X
IN01094004A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine