Provider Demographics
NPI:1174330112
Name:JOHNSON, SAMANTHA VAN DYKE (MD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:VAN DYKE
Last Name:JOHNSON
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 1:282 QUARI ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8340
Mailing Address - Country:US
Mailing Address - Phone:912-245-5510
Mailing Address - Fax:
Practice Address - Street 1:13001 E 17TH PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2570
Practice Address - Country:US
Practice Address - Phone:575-218-5936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0010600390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program