Provider Demographics
NPI:1508861725
Name:SAMUELSON, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 N CENTRAL EXPY
Mailing Address - Street 2:#360
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3140
Mailing Address - Country:US
Mailing Address - Phone:214-252-3511
Mailing Address - Fax:
Practice Address - Street 1:4144 N CENTRAL EXPY
Practice Address - Street 2:#360
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3140
Practice Address - Country:US
Practice Address - Phone:214-252-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8423207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122564104Medicaid
TXP00957309OtherRAILROAD MEDICARE
TX122564105Medicaid
TX8A1509OtherBCBS
TX122564106OtherMEDICAID CSHCN
TX88X311Medicare ID - Type Unspecified
TX122564106OtherMEDICAID CSHCN
TX122564104Medicaid