Provider Demographics
NPI:1053336339
Name:KAZANCHI, JOSEPH SAM (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:SAM
Last Name:KAZANCHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YASER
Other - Middle Name:SAMIR
Other - Last Name:YOUSIF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:619-260-7125
Mailing Address - Fax:
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:MER 127
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-484-8573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90062207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200726350BMedicaid
003719124OtherMEDICARE