Provider Demographics
NPI:1629605480
Name:DEMOSS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DEMOSS
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 1:1215 HADLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2907
Mailing Address - Country:US
Mailing Address - Phone:317-834-9618
Mailing Address - Fax:
Practice Address - Street 1:1215 HADLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2907
Practice Address - Country:US
Practice Address - Phone:317-834-9618
Practice Address - Fax:317-831-9467
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01095693B208600000X
390200000X
IL125.075907208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program