Provider Demographics
NPI:1629016993
Name:SAMANIEGO, LORETTA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:M
Last Name:SAMANIEGO
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 1:2550 N HOLLYWOOD WAY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1055
Mailing Address - Country:US
Mailing Address - Phone:818-557-0135
Mailing Address - Fax:818-557-1394
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-902-2990
Practice Address - Fax:818-904-3793
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79859207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G798590OtherBLUE SHIELD
CA00G798590Medicaid
CA050126CG22530OtherVALLEY PRES TRAILBLAZER
CA00G798590OtherCALOPTIMA
CAG79859OtherBLUE CROSS
CA00G798590OtherCALOPTIMA
CA00G798590Medicaid