Provider Demographics
NPI:1245644384
Name:BLANK, SAMANTHA (MD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BLANK
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 1:810 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-4514
Mailing Address - Country:US
Mailing Address - Phone:773-636-2297
Mailing Address - Fax:
Practice Address - Street 1:355 UNION BLVD STE 360
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1528
Practice Address - Country:US
Practice Address - Phone:720-651-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-065333207R00000X
MA270421207R00000X
IL036.148940207RN0300X
CODR.0065833207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine