Provider Demographics
NPI:1336353366
Name:FORT WORTH ENT,P.A.
Entity type:Organization
Organization Name:FORT WORTH ENT,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANVLECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-335-8151
Mailing Address - Street 1:1250 8TH AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-335-8151
Mailing Address - Fax:817-335-2670
Practice Address - Street 1:1250 8TH AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-335-8151
Practice Address - Fax:817-335-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2007174400000X
TXL4150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2131OtherTODD E. SAMUELSON MD BCBS
TX031074002Medicaid
TX166927701Medicaid
TXH2007OtherTODD E SAMUELSON MD LICEN
TX166927701Medicaid
TX8K1145Medicare PIN
TXD67714Medicare UPIN
TXH2007OtherTODD E SAMUELSON MD LICEN
TXH58176Medicare UPIN