Basic Information
| Provider Information | |||||||||
| NPI: | 1336353366 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT WORTH ENT,P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FORT WORTH ENT, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 8TH AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 8TH AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANVLECK | ||||||||
| AuthorizedOfficialFirstName: | VICKY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8173358151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | L4150 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | H2007 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8G2131 | 01 | TX | TODD E. SAMUELSON MD BCBS | OTHER | 031074002 | 05 | TX | MEDICAID | 166927701 | 05 | TX | MEDICAID | H2007 | 01 | TX | TODD E SAMUELSON MD LICEN | OTHER |