Provider Demographics
NPI:1043806995
Name:CHENG, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:CHENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 W BROADWAY APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2177
Mailing Address - Country:US
Mailing Address - Phone:631-747-8371
Mailing Address - Fax:
Practice Address - Street 1:308 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1243
Practice Address - Country:US
Practice Address - Phone:660-642-5911
Practice Address - Fax:660-248-2217
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2024022777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program