Provider Demographics
NPI:1376980649
Name:DAYAWANSA, SAMANTHA (MD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:DAYAWANSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1372
Mailing Address - Country:US
Mailing Address - Phone:716-998-4062
Mailing Address - Fax:
Practice Address - Street 1:5500 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1372
Practice Address - Country:US
Practice Address - Phone:716-998-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95099207T00000X
TXV8608207T00000X
IN01096248A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery