Provider Demographics
NPI:1679579312
Name:SAMLOWSKI, EBERHARD ROY (MD)
Entity Type:Individual
Prefix:
First Name:EBERHARD
Middle Name:ROY
Last Name:SAMLOWSKI
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 742712
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2712
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:17218 PRESTON RD STE 2000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-4018
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:817-202-8354
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1380208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105715002Medicaid
TX105715004Medicaid
TX882580Medicare ID - Type Unspecified