Provider Demographics
NPI:1689870990
Name:SAFAVI-ABBASI, SAM (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:SAFAVI-ABBASI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:1001 WILLOW CREEK RD STE 3300
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-458-2996
Practice Address - Fax:928-458-2135
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ49003207T00000X, 207T00000X
OK25808207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ907411Medicaid
AZZ166194Medicare PIN