Provider Demographics
NPI:1649668146
Name:SAMANDAR, STELLA
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:SAMANDAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20925 18TH AVE
Mailing Address - Street 2:6G
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1453
Mailing Address - Country:US
Mailing Address - Phone:646-322-0423
Mailing Address - Fax:
Practice Address - Street 1:20925 18TH AVE
Practice Address - Street 2:6G
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1453
Practice Address - Country:US
Practice Address - Phone:646-322-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist