Healthcare Provider Details

I. General information

NPI: 1497029391
Provider Name (Legal Business Name): MIREYA SAMANIEGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 W HERNDON AVE # 110
FRESNO CA
93722-8401
US

IV. Provider business mailing address

6000 N FIGUEROA ST
LOS ANGELES CA
90042-4232
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-0463
  • Fax: 559-450-0464
Mailing address:
  • Phone: 323-254-5291
  • Fax: 323-254-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA123728
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA123728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: