Healthcare Provider Details

I. General information

NPI: 1922637149
Provider Name (Legal Business Name): RICHARD WYATT SAMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7941 CASTLEWAY DR
INDIANAPOLIS IN
46250-1953
US

IV. Provider business mailing address

7941 CASTLEWAY DR
INDIANAPOLIS IN
46250-1953
US

V. Phone/Fax

Practice location:
  • Phone: 317-741-9122
  • Fax:
Mailing address:
  • Phone: 317-408-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: