Provider Demographics
NPI:1851514046
Name:DAVIS, SAMUEL H (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:H
Last Name:DAVIS
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:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:
Practice Address - Street 1:604 E BAILEY BOSWELL RD STE 140
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76131-3568
Practice Address - Country:US
Practice Address - Phone:817-484-6610
Practice Address - Fax:817-423-7476
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM71342080P0207X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DE492OtherBCBS OF TEXAS
TX186562803Medicaid
TX1851514046OtherTRICARE
TX8F9944OtherBCBS
TX186562804OtherCSHCN
TX8F9944OtherBCBS
TX186562803Medicaid
TX137345810OtherCSHCN GROUP
TX140442852OtherMEDICAID GROUP
TX8L6618Medicare PIN