Provider Demographics
NPI:1306532734
Name:SAMPSON, SHANE (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SAMPSON
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 1:3990 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2018
Mailing Address - Country:US
Mailing Address - Phone:313-745-6035
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE, STE.
Practice Address - Street 2:8C-UHC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-1302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43015146092084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology