Provider Demographics
NPI:1356848386
Name:FLECKENSTEIN, SAMANTHA J
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:FLECKENSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MAYHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:4001 W GOELLER BLVD STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-8309
Practice Address - Country:US
Practice Address - Phone:812-375-3330
Practice Address - Fax:812-375-3329
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086237207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine