Provider Demographics
NPI:1396988184
Name:SAM, MICHAEL JOSEPH (IDC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SAM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 WOMBLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-0001
Mailing Address - Country:US
Mailing Address - Phone:619-556-6641
Mailing Address - Fax:619-556-9617
Practice Address - Street 1:SWRMC 3601 WOMBLE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-0001
Practice Address - Country:US
Practice Address - Phone:619-556-6641
Practice Address - Fax:619-556-9617
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P0900513146L00000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic