MEDICARE: SAMANTHA LOUISE JACKSON-DILTS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	61798	TN
2	208000000X	Pediatrics Physician	002952	GA
3	208000000X	Pediatrics Physician	D78881	MD
4	208000000X	Pediatrics Physician	0101269251	VA

General Provider Information

NPI Number	:	1821256801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LOUISE JACKSON-DILTS M.D.

Provider Business Mailing Address
First Line	:	1 HOLLOW LN STE 301
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1215
Country	:	US
Telephone Number	:	516-207-7851
Fax Number	:	516-207-7851

Provider Business Practice Location Address
First Line	:	2301A FOREST DR
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-3833
Country	:	US
Telephone Number	:	410-266-6767
Fax Number	:	410-266-6761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	02/16/2022

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