Provider Demographics
NPI:1275669558
Name:SAMORODIN-MCILWAIN, JANET ELEANOR (DO)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:ELEANOR
Last Name:SAMORODIN-MCILWAIN
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 1:3410 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-265-7817
Mailing Address - Fax:505-266-1543
Practice Address - Street 1:3410 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-265-7817
Practice Address - Fax:505-266-1543
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1430-07208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84774525Medicaid
NM84774525Medicaid
I38608Medicare UPIN