Provider Demographics
NPI:1497070353
Name:BLAKESLEE, SAMANTHA (DO)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BLAKESLEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:401 ROUTE 73 N STE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3426
Mailing Address - Country:US
Mailing Address - Phone:856-795-3320
Mailing Address - Fax:856-795-1213
Practice Address - Street 1:710 KRESSON RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2604
Practice Address - Country:US
Practice Address - Phone:856-795-3320
Practice Address - Fax:856-795-1213
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016691208000000X
NJ25MB092244002080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028913600001Medicaid