Provider Demographics
NPI:1598526444
Name:PUTNAM, SAMANTHA DANIELLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:DANIELLE
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1914
Mailing Address - Country:US
Mailing Address - Phone:757-446-5600
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1912
Practice Address - Country:US
Practice Address - Phone:757-446-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01100103072080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep MedicineGroup - Multi-Specialty