Healthcare Provider Details

I. General information

NPI: 1215991856
Provider Name (Legal Business Name): SAMUEL R CHACON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 W PLUMB LN STE 200
RENO NV
89509-3683
US

IV. Provider business mailing address

540 W PLUMB LN STE 200
RENO NV
89509-3683
US

V. Phone/Fax

Practice location:
  • Phone: 775-870-1521
  • Fax: 775-870-1892
Mailing address:
  • Phone: 775-870-1521
  • Fax: 775-870-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number9105
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9105
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: