1790837425 NPI number — SAMANTHA CHILDERS DPM

Table of content: SAMANTHA CHILDERS DPM (NPI 1790837425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790837425 NPI number — SAMANTHA CHILDERS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDERS
Provider First Name:
SAMANTHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790837425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1224 N HIGHWAY 377 # 303-151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-9103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-674-7494
Provider Business Mailing Address Fax Number:
855-880-6990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
351 W. BYRON NELSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-602-2048
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  1931 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: #8FV228 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 355509601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".