Healthcare Provider Details

I. General information

NPI: 1588655047
Provider Name (Legal Business Name): SAMANTHA ANDRIEN STEWART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 ROSE AVE
VENICE CA
90291-2767
US

IV. Provider business mailing address

255 HORIZON AVE
VENICE CA
90291-3713
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-8636
  • Fax:
Mailing address:
  • Phone: 310-664-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC55267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: