Provider Demographics
NPI:1942308119
Name:SAMUELSON, TODD E (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:E
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO 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:817-926-2531
Practice Address - Street 1:1250 8TH AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4158
Practice Address - Country:US
Practice Address - Phone:817-335-8151
Practice Address - Fax:817-926-2531
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH2007207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01034921OtherRAILROAD MEDICARE
TX130524508Medicaid