1336353366 NPI number — FORT WORTH ENT,P.A.

Table of content: (NPI 1336353366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336353366 NPI number — FORT WORTH ENT,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WORTH ENT,P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FORT WORTH ENT, PA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336353366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 8TH AVE
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-335-8151
Provider Business Mailing Address Fax Number:
817-335-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-335-8151
Provider Business Practice Location Address Fax Number:
817-335-2670
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANVLECK
Authorized Official First Name:
VICKY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
817-335-8151

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  H2007 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: L4150 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8G2131 . This is a "TODD E. SAMUELSON MD BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 031074002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166927701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: H2007 . This is a "TODD E SAMUELSON MD LICEN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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