Provider Demographics
NPI:1679102503
Name:CORDUM, SAMANTHA N (MD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:N
Last Name:CORDUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CROSS OAK DR UNIT 5
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9074
Mailing Address - Country:US
Mailing Address - Phone:208-608-4299
Mailing Address - Fax:
Practice Address - Street 1:301 CROSS OAK DR UNIT 5
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-9074
Practice Address - Country:US
Practice Address - Phone:208-608-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-015752080N0001X
WI17452080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine