Healthcare Provider Details

I. General information

NPI: 1720246929
Provider Name (Legal Business Name): SAMANTHA ELIZABETH BARK DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2008
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 HOSFORD RD
GALION OH
44833-9325
US

IV. Provider business mailing address

955 HOSFORD RD
GALION OH
44833-9325
US

V. Phone/Fax

Practice location:
  • Phone: 419-468-7059
  • Fax: 419-468-6962
Mailing address:
  • Phone: 419-468-7059
  • Fax: 419-468-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number003623
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: