Provider Demographics
NPI:1932143823
Name:BUCHANAN, SAM W JR (DO)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:W
Last Name:BUCHANAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 100937
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0937
Mailing Address - Country:US
Mailing Address - Phone:817-313-4616
Mailing Address - Fax:817-333-0173
Practice Address - Street 1:800 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4611
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-333-0173
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE4229208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1042053-03Medicaid
TXTXB103597Medicare PIN