Provider Demographics
NPI:1831167162
Name:HESSAMI, SAM H (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:H
Last Name:HESSAMI
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 1:400 N PEPPER AVE # 206
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-2270
Mailing Address - Fax:909-580-3289
Practice Address - Street 1:400 N PEPPER AVE # 206
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-2270
Practice Address - Fax:909-580-3289
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG149086207VF0040X, 207V00000X
NJ25MA06718800207VG0400X
NY209108207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG149086OtherCALIFORNIA MEDICAL LICENSE
NJ7383605Medicaid
NJ011041Medicare ID - Type Unspecified