Provider Demographics
NPI:1538179916
Name:DAGGUBATI, SAM (MD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:DAGGUBATI
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 1:1309 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-3509
Mailing Address - Country:US
Mailing Address - Phone:325-673-1322
Mailing Address - Fax:325-675-6514
Practice Address - Street 1:1309 HICKORY ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-3509
Practice Address - Country:US
Practice Address - Phone:325-673-1322
Practice Address - Fax:325-675-6514
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00AD18OtherBLUE CROSS BLUE SHIELD
TX113974301Medicaid
TX111171100OtherFIRSTCARE
TX111171100OtherFIRSTCARE
TX00AD18OtherBLUE CROSS BLUE SHIELD