Provider Demographics
NPI:1871782466
Name:JOHAN SAMANTA, MD PC
Entity type:Organization
Organization Name:JOHAN SAMANTA, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAMANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-277-2228
Mailing Address - Street 1:7500 N DREAMY DRAW DR
Mailing Address - Street 2:SUITE 133
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:602-277-2228
Mailing Address - Fax:602-265-9494
Practice Address - Street 1:7500 N DREAMY DRAW DR
Practice Address - Street 2:SUITE 133
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4668
Practice Address - Country:US
Practice Address - Phone:602-277-2228
Practice Address - Fax:602-265-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25284261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center