Provider Demographics
NPI:1023546348
Name:SAMEDOVA, ANNA NIKOLAEVNA (DO)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:NIKOLAEVNA
Last Name:SAMEDOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:SEVILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:854 ROUTE 212
Practice Address - Street 2:SAUGERTIES WELLNESS CENTER
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-4619
Practice Address - Country:US
Practice Address - Phone:845-246-2804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302842207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program