Healthcare Provider Details

I. General information

NPI: 1699115402
Provider Name (Legal Business Name): IMEH SAMPSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

10401 W THUNDERBIRD BLVD
SUN CITY AZ
85351-3004
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-2353
  • Fax:
Mailing address:
  • Phone: 623-832-4728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number109630
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number283895
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number283895
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: