Provider Demographics
NPI:1134138126
Name:SAMFORD, ROBIN RENEE (LSA)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:RENEE
Last Name:SAMFORD
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W 5TH STREET #470
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761
Mailing Address - Country:US
Mailing Address - Phone:432-580-8330
Mailing Address - Fax:432-580-8333
Practice Address - Street 1:540 W 5TH ST STE 470
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5070
Practice Address - Country:US
Practice Address - Phone:432-580-8330
Practice Address - Fax:432-580-8333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00093246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00455QOtherMEDICARE PROVIDER ID
TX071693OtherNATNL CERT SURGICAL TECH
TXSA00093OtherTEXAS STATE BOARD OF MEDI
TX83628OtherNAT CERT SURGICAL TECH
8F0641OtherBLUE CROSS PROVIDER #