Provider Demographics
NPI:1962899773
Name:SAM, SONY (MD)
Entity type:Individual
Prefix:DR
First Name:SONY
Middle Name:
Last Name:SAM
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 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:813-754-5480
Mailing Address - Fax:
Practice Address - Street 1:228 W ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563
Practice Address - Country:US
Practice Address - Phone:813-754-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2494207Q00000X
DEC1-0013226207Q00000X
CT64045207Q00000X
FLME128236207Q00000X
NY280515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine