Provider Demographics
NPI:1063672608
Name:HANCOCK, SAMUEL BRANDON (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BRANDON
Last Name:HANCOCK
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 1:1705 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3041
Mailing Address - Country:US
Mailing Address - Phone:405-285-7500
Mailing Address - Fax:405-285-7501
Practice Address - Street 1:4510 NW 39TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73122-2503
Practice Address - Country:US
Practice Address - Phone:405-495-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK265462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK404647Medicare PIN