Healthcare Provider Details

I. General information

NPI: 1053220152
Provider Name (Legal Business Name): SAMANTHA TINA STORDEUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD HSC T12 RM 080
STONY BROOK NY
11794-8122
US

IV. Provider business mailing address

100 NICOLLS RD HSC T12 RM 080
STONY BROOK NY
11794-8122
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1116
  • Fax: 631-444-1535
Mailing address:
  • Phone: 631-444-1116
  • Fax: 631-444-1535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036468
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: