Provider Demographics
NPI:1891375465
Name:BLACK, SAMANTHA MONIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MONIQUE
Last Name:BLACK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:1615 HOSPITAL PKWY STE 306
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5936
Practice Address - Country:US
Practice Address - Phone:817-684-5100
Practice Address - Fax:817-684-5101
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV6875207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology