Provider Demographics
NPI:1558462663
Name:SAMOVAR, JILL BETH (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:BETH
Last Name:SAMOVAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:BETH
Other - Last Name:GOLDSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11600 INDIAN HILLS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1225
Mailing Address - Country:US
Mailing Address - Phone:818-838-4542
Mailing Address - Fax:818-838-7520
Practice Address - Street 1:11600 INDIAN HILLS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1225
Practice Address - Country:US
Practice Address - Phone:818-838-4542
Practice Address - Fax:818-838-7520
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84520Medicare UPIN