Healthcare Provider Details

I. General information

NPI: 1609453679
Provider Name (Legal Business Name): SAMANTHA GRACE ONGCHUAN MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 JONESTOWN RD
WINSTON SALEM NC
27103-1252
US

IV. Provider business mailing address

791 JONESTOWN RD
WINSTON SALEM NC
27103-1252
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4551
  • Fax: 336-716-8630
Mailing address:
  • Phone: 336-716-4551
  • Fax: 336-716-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2025-00005
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025-00005
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: