Provider Demographics
NPI:1467814954
Name:KIEDROWSKI, SAMANTHA (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KIEDROWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:DUSEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:725 HAMLINE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-2819
Mailing Address - Country:US
Mailing Address - Phone:701-780-6864
Mailing Address - Fax:701-780-4391
Practice Address - Street 1:725 HAMLINE ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2819
Practice Address - Country:US
Practice Address - Phone:701-780-6864
Practice Address - Fax:701-780-4391
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15261207Q00000X
NDRL14147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine