Provider Demographics
NPI:1831504067
Name:SAMSON, SHOJI OLIVO (DO)
Entity type:Individual
Prefix:DR
First Name:SHOJI
Middle Name:OLIVO
Last Name:SAMSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NS GLEN OAK AVENUE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:096-242-8963
Mailing Address - Fax:
Practice Address - Street 1:530 NS GLEN OAK AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-624-2896
Practice Address - Fax:309-655-2974
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0375208000000X, 2080N0001X
IADO-05910208000000X, 2080N0001X
NY288816208000000X, 2080N0001X
IL036152483208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty