Provider Demographics
NPI:1215382130
Name:EZRIN, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:EZRIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:COOPERBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 OLD COUNTRY RD
Mailing Address - Street 2:APT 118
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4303
Mailing Address - Country:US
Mailing Address - Phone:516-220-8985
Mailing Address - Fax:
Practice Address - Street 1:140 OLD COUNTRY RD
Practice Address - Street 2:APT 118
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4303
Practice Address - Country:US
Practice Address - Phone:516-220-8985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY818855141174400000X
NY818502141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist