Provider Demographics
NPI:1114956539
Name:SAMUEL, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SAMUEL
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 1:4325 N JOSEY LN STE 211
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4637
Mailing Address - Country:US
Mailing Address - Phone:214-483-5665
Mailing Address - Fax:214-483-5684
Practice Address - Street 1:4325 N JOSEY LN STE 211
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4637
Practice Address - Country:US
Practice Address - Phone:214-483-5665
Practice Address - Fax:214-483-5684
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM02522084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00207238OtherRR MEDICARE
TX8G4625OtherBCBS
TX172460101Medicaid
TX172460102Medicaid
TX172460103Medicaid
TX172460102Medicaid
TX172460103Medicaid
TXP00207238OtherRR MEDICARE
I27798Medicare UPIN