Provider Demographics
NPI:1821256801
Name:JACKSON-DILTS, SAMANTHA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:JACKSON-DILTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:LOUISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 HOLLOW LN STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1215
Mailing Address - Country:US
Mailing Address - Phone:516-207-7851
Mailing Address - Fax:516-207-7851
Practice Address - Street 1:2301A FOREST DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3833
Practice Address - Country:US
Practice Address - Phone:410-266-6767
Practice Address - Fax:410-266-6761
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61798208000000X
GA002952208000000X
MDD78881208000000X
VA0101269251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics