Provider Demographics
NPI:1992390397
Name:GATEWOOD, SAMANTHA JAYE (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JAYE
Last Name:GATEWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-2801
Mailing Address - Country:US
Mailing Address - Phone:312-259-6627
Mailing Address - Fax:
Practice Address - Street 1:600 W CHICAGO AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-2802
Practice Address - Country:US
Practice Address - Phone:312-625-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022251208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice