Provider Demographics
NPI:1841386356
Name:SAMUDIO, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:SAMUDIO
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 1:4240 HIGHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-2764
Mailing Address - Country:US
Mailing Address - Phone:909-864-4700
Mailing Address - Fax:909-864-4300
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 516
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-881-1722
Practice Address - Fax:909-883-6011
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82448174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A824480Medicaid
CAI19663Medicare UPIN
CA00A824480Medicaid