Basic Information
| Provider Information | |||||||||
| NPI: | 1629016993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMANIEGO | ||||||||
| FirstName: | LORETTA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 N HOLLYWOOD WAY | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915051055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185570135 | ||||||||
| FaxNumber: | 8185571394 | ||||||||
| Practice Location | |||||||||
| Address1: | 15107 VANOWEN ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914054542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189022990 | ||||||||
| FaxNumber: | 8189043793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G79859 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G798590 | 01 | CA | BLUE SHIELD | OTHER | 00G798590 | 05 | CA | MEDICAID | 050126CG22530 | 01 | CA | VALLEY PRES TRAILBLAZER | OTHER | 00G798590 | 01 | CA | CALOPTIMA | OTHER | G79859 | 01 | CA | BLUE CROSS | OTHER |