Provider Demographics
NPI:1215178090
Name:AVERY, SAMANTHA R (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:R
Last Name:AVERY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PASADENA AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4567
Mailing Address - Country:US
Mailing Address - Phone:727-490-3030
Mailing Address - Fax:866-200-9885
Practice Address - Street 1:1615 PASADENA AVE S STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4567
Practice Address - Country:US
Practice Address - Phone:277-490-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS 11371207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHT787ZOtherMEDICARE ID-TYPE UNSPECIFIED