Healthcare Provider Details

I. General information

NPI: 1912435579
Provider Name (Legal Business Name): SHASHANK SAMA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date: 01/03/2018
Reactivation Date: 01/24/2018

III. Provider practice location address

30 N 1900 E RM 5C402
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM 5C402
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-3229
  • Fax:
Mailing address:
  • Phone: 801-585-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number11760826-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number11760826-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: