Provider Demographics
NPI:1932366705
Name:SAMIMI, ROODABEH (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROODABEH
Middle Name:
Last Name:SAMIMI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:336-277-6550
Mailing Address - Fax:
Practice Address - Street 1:2825 LYNDHURST AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4146
Practice Address - Country:US
Practice Address - Phone:336-277-6550
Practice Address - Fax:336-768-1026
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006352213ES0103X
CAE4847213ES0103X
NC593213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3097625Medicaid
OH3097625Medicaid