Provider Demographics
NPI:1891994224
Name:HARALDSON, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:HARALDSON
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 1:1651 W ROSEDALE ST
Mailing Address - Street 2:#200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7437
Mailing Address - Country:US
Mailing Address - Phone:817-335-4316
Mailing Address - Fax:817-336-2504
Practice Address - Street 1:1651 W ROSEDALE ST
Practice Address - Street 2:#200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-335-4316
Practice Address - Fax:817-336-2504
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9230207P00000X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine