Provider Demographics
NPI:1912015165
Name:SAMUELSON, BRADLEY E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:E
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 1:1004 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5007
Mailing Address - Country:US
Mailing Address - Phone:940-687-7100
Mailing Address - Fax:940-687-7104
Practice Address - Street 1:1004 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5007
Practice Address - Country:US
Practice Address - Phone:940-687-7100
Practice Address - Fax:940-687-7104
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5005207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1022402-04Medicaid
TXE90556Medicare UPIN
TX8D4035Medicare PIN