Provider Demographics
NPI:1336677186
Name:FANTAYE, SAMUEL HAILEMARIAM (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HAILEMARIAM
Last Name:FANTAYE
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 1:20642 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20642 JOHN DR
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5103
Practice Address - Country:US
Practice Address - Phone:510-857-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA169452207QB0002X, 207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine