Provider Demographics
NPI:1164125951
Name:LEADBETTER, SAMANTHA CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:CLARK
Last Name:LEADBETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:YVONNE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:401 RAILROAD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4178
Mailing Address - Country:US
Mailing Address - Phone:406-258-4789
Mailing Address - Fax:406-258-4732
Practice Address - Street 1:401 RAILROAD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4178
Practice Address - Country:US
Practice Address - Phone:406-258-4789
Practice Address - Fax:406-258-4732
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTMED-RES-LIC-142042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine