Provider Demographics
NPI:1558041103
Name:SAMAAN, HAIDY
Entity type:Individual
Prefix:
First Name:HAIDY
Middle Name:
Last Name:SAMAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 LA SALLE CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-7923
Mailing Address - Country:US
Mailing Address - Phone:949-549-1500
Mailing Address - Fax:
Practice Address - Street 1:1671 W KATELLA AVE STE 245
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-3053
Practice Address - Country:US
Practice Address - Phone:949-549-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558041103OtherNPI