Provider Demographics
NPI:1700076874
Name:VORKPOR, SAM GBUTUE (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:GBUTUE
Last Name:VORKPOR
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 1:509 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-8813
Mailing Address - Fax:
Practice Address - Street 1:509 MEMORIAL DR STE 2
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6196
Practice Address - Country:US
Practice Address - Phone:606-598-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100054150Medicaid
KY7100054150Medicaid
VAP00662715Medicare PIN
VAMC11885Medicare PIN