Provider Demographics
NPI:1144218363
Name:SAMTER, JORDAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:SAMTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17841 GREEN WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2242
Mailing Address - Country:US
Mailing Address - Phone:813-907-1215
Mailing Address - Fax:
Practice Address - Street 1:10549 N FLORIDA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6707
Practice Address - Country:US
Practice Address - Phone:813-978-1522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL193315OtherHEALTHEASE
FL193315OtherSTAYWELL
FL9841OtherBLUE CROSS AND BLUE SHIEL
FL593618517OtherHUMANA
FL4950862005OtherCIGNA
FL2064658OtherAETNA
FL206926OtherAMERIGROUP
FL247082OtherAVMED
FL252231400Medicaid
FL593618517OtherUNITED HEALTHCARE
FL4950862005OtherCIGNA