Healthcare Provider Details

I. General information

NPI: 1497960470
Provider Name (Legal Business Name): SAMUEL HERBERT SANDWEISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 AMIFORD DR
SAN DIEGO CA
92107-4254
US

IV. Provider business mailing address

767 AMIFORD DR
SAN DIEGO CA
92107-4254
US

V. Phone/Fax

Practice location:
  • Phone: 619-224-7586
  • Fax: 619-225-9401
Mailing address:
  • Phone: 619-224-7586
  • Fax: 619-225-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberC282970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: