Provider Demographics
NPI:1598085474
Name:MEDINA, SAMANTHA LOUISE (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:LOUISE
Other - Last Name:SORNSIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6678 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3721
Mailing Address - Country:US
Mailing Address - Phone:602-978-1500
Mailing Address - Fax:602-978-0409
Practice Address - Street 1:6678 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3721
Practice Address - Country:US
Practice Address - Phone:602-978-1500
Practice Address - Fax:602-978-0409
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006385207V00000X
AZR1784207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1598085474OtherNPI