Basic Information
Provider Information | |||||||||
NPI: | 1891994224 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARALDSON | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1651 W ROSEDALE ST | ||||||||
Address2: | #200 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761047437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173354316 | ||||||||
FaxNumber: | 8173362504 | ||||||||
Practice Location | |||||||||
Address1: | 1651 W ROSEDALE ST | ||||||||
Address2: | #200 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761047437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173354316 | ||||||||
FaxNumber: | 8173362504 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2007 | ||||||||
LastUpdateDate: | 02/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L9230 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PS0010X | L9230 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
No ID Information.