Provider Demographics
NPI:1649736307
Name:SAMARDAK, ERICK DAVID
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:DAVID
Last Name:SAMARDAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ABBEYDELL
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-5103
Mailing Address - Country:US
Mailing Address - Phone:301-910-4747
Mailing Address - Fax:
Practice Address - Street 1:159 MONTAGUE DR
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003
Practice Address - Country:US
Practice Address - Phone:830-460-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202172164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse