Basic Information
| Provider Information | |||||||||
| NPI: | 1740512649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMEERUDDIN | ||||||||
| FirstName: | SYED | ||||||||
| MiddleName: | RAHEEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035101186 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | P5466 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 332769401 | 05 | TX | MEDICAID | 8EB356 | 01 | TX | BCBS BLUE | OTHER | 75-2616977-042 | 01 | TX | TRICARE | OTHER |