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General NPI Number Information
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NPI Number | 1013443480
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Entity Type | Individual
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Provider Name | DERICA NICOLE SAMS M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/04/2017
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Last Update Date | 01/09/2025
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Provider Practice Location Address
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Address Line | 3925 HARRISON RD STE 100
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City | LOGANVILLE
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State | GA
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Zip | 30052-5898
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Country | US
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Telephone | 770-274-4222
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Fax | 770-284-3187
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Provider Business Mailing Address
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Address Line | 3925 HARRISON RD STE 100
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City | LOGANVILLE
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State | GA
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Zip | 30052-5898
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Country | US
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Telephone | 770-274-4222
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Fax | 770-284-3187
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 227179
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number | 97229
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License Number State | GA
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