Provider Demographics
NPI:1629171434
Name:HADDOCK, SAMUEL T (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:HADDOCK
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:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4095
Practice Address - Fax:682-885-7499
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0812207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX006041002Medicaid
TX124211OtherSUPERIOR PIN
TX2840117OtherCIGNA PIN
TX006041003Medicaid
TX5297726OtherAETNA PIN
TX00L42VOtherBCBSTX GRP PIN
TX137283103Medicaid
TX8H8785OtherBCBSTX IND PIN
TX138456101OtherFIRSTCARE PIN
TX1746111OtherFIRSTHEALTH PIN
TX1866576OtherUHC PIN
TX10032051OtherAMERIGROUP PIN
1669442042OtherGRP NPI NUMBER
TX137345805Medicaid
TX1746111OtherFIRSTHEALTH PIN
TX5297726OtherAETNA PIN
TX00L42VOtherBCBSTX GRP PIN
TX006041003Medicaid