Provider Demographics
NPI:1790837425
Name:CHILDERS, SAMANTHA (DPM)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 N HIGHWAY 377 # 303-151
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9103
Mailing Address - Country:US
Mailing Address - Phone:817-674-7494
Mailing Address - Fax:855-880-6990
Practice Address - Street 1:351 W. BYRON NELSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262
Practice Address - Country:US
Practice Address - Phone:415-602-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1931213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX#8FV228OtherBCBSTX
TX355509601Medicaid
TX355509601Medicaid