Provider Demographics
NPI:1518351428
Name:SHIPMAN, SAMANTHA (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SHIPMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BUTTERCUP DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2910
Mailing Address - Country:US
Mailing Address - Phone:870-425-3030
Mailing Address - Fax:
Practice Address - Street 1:405 BUTTERCUP DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-28
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE10924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty