Provider Demographics
NPI:1679033062
Name:RALSTIN, SAMANTHA MAXINE (DPM)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MAXINE
Last Name:RALSTIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MCKINNEY AVE APT 445
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3560
Mailing Address - Country:US
Mailing Address - Phone:805-240-6655
Mailing Address - Fax:214-550-2099
Practice Address - Street 1:1320 N GALLOWAY AVE STE 105
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2461
Practice Address - Country:US
Practice Address - Phone:214-550-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2086213EP1101X
TX692130213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine