Provider Demographics
NPI:1366570855
Name:TREDEMEYER, SAMUEL (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:TREDEMEYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1892
Mailing Address - Country:US
Mailing Address - Phone:469-322-7481
Mailing Address - Fax:469-322-7807
Practice Address - Street 1:4400 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1892
Practice Address - Country:US
Practice Address - Phone:469-322-7481
Practice Address - Fax:469-322-7807
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2386207R00000X
MI5101016014207R00000X
WI2979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16150185OtherMEDICARE