Provider Demographics
NPI:1407436603
Name:DIA, SAMMY ELIAS (MD)
Entity type:Individual
Prefix:
First Name:SAMMY
Middle Name:ELIAS
Last Name:DIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35 MICHIGAN ST NE STE 5301
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2530
Mailing Address - Country:US
Mailing Address - Phone:616-391-8842
Mailing Address - Fax:616-391-2978
Practice Address - Street 1:35 MICHIGAN ST NE STE 5301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2530
Practice Address - Country:US
Practice Address - Phone:616-391-8842
Practice Address - Fax:616-391-2978
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43510481462080H0002X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program