Basic Information
| Provider Information | |||||||||
| NPI: | 1831167162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HESSAMI | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N PEPPER AVE # 206 | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095802270 | ||||||||
| FaxNumber: | 9095803289 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE # 206 | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095802270 | ||||||||
| FaxNumber: | 9095803289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | G149086 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207VG0400X | 25MA06718800 | NJ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VG0400X | 209108 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | G149086 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | G149086 | 01 | CA | CALIFORNIA MEDICAL LICENSE | OTHER | 7383605 | 05 | NJ | MEDICAID |