Healthcare Provider Details

I. General information

NPI: 1639129570
Provider Name (Legal Business Name): MARINA ZIMARA SAMPAGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MACNISH ST
ELMHURST NY
11373
US

IV. Provider business mailing address

9309 74TH PLACE
WOODHAVEN NY
11421
US

V. Phone/Fax

Practice location:
  • Phone: 718-424-0782
  • Fax:
Mailing address:
  • Phone: 917-885-5205
  • Fax: 718-296-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number157254
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00811174
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: