Provider Demographics
NPI:1063083152
Name:COGO, SAMUEL L
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:COGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8815
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95208-0815
Mailing Address - Country:US
Mailing Address - Phone:209-981-2936
Mailing Address - Fax:
Practice Address - Street 1:4370 CONTRACTORS CMN
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-7544
Practice Address - Country:US
Practice Address - Phone:209-981-2936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty