Provider Demographics
NPI:1215757620
Name:ARDITO, SAMUEL (MED)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:ARDITO
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 N MILL ST STE F
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-4872
Mailing Address - Country:US
Mailing Address - Phone:630-536-8073
Mailing Address - Fax:
Practice Address - Street 1:1813 N MILL ST STE F
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4872
Practice Address - Country:US
Practice Address - Phone:630-536-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1427365527OtherBRIDGEVIEW CLINICAL SERVICES