Provider Demographics
NPI:1215178090
Name:AVERY, SAMANTHA R (DO)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:R
Last Name:AVERY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6218
Mailing Address - Country:US
Mailing Address - Phone:407-719-3370
Mailing Address - Fax:917-831-4677
Practice Address - Street 1:1615 PASADENA AVE S STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4567
Practice Address - Country:US
Practice Address - Phone:277-490-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016407207RC0000X
PAOS022821207RC0000X
ORDO214145207RC0000X
IN01089349A207RC0000X
CT73591207RC0000X
FLOS 11371207RC0000X
AZ010143207RC0000X
CODR.0070152207RC0000X
SC92684207RC0000X
NY339916207RC0000X
NC25MB11818700207RC0000X
NMDO2023-1051207RC0000X
NVDO3464207RC0000X
NJ25MB11818700207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHT787ZOtherMEDICARE ID-TYPE UNSPECIFIED