Healthcare Provider Details

I. General information

NPI: 1700168028
Provider Name (Legal Business Name): DONALD R SAMPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MONTICELLO RD
COLUMBIA SC
29203-4156
US

IV. Provider business mailing address

261 BUSINESS PARK BLVD # 913
COLUMBIA SC
29203-8915
US

V. Phone/Fax

Practice location:
  • Phone: 803-754-0151
  • Fax:
Mailing address:
  • Phone: 803-708-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11585
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: