Provider Demographics
NPI:1912740390
Name:DERDIGER, SAMARA (RDN)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:DERDIGER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20817 N HORATIO BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069-9614
Mailing Address - Country:US
Mailing Address - Phone:847-946-3289
Mailing Address - Fax:
Practice Address - Street 1:20817 N HORATIO BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-9614
Practice Address - Country:US
Practice Address - Phone:847-946-3289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007793133V00000X
IL164009053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered