Organization
FORT WORTH ENT,P.A.
Active
Other names
FORT WORTH ENT, PA
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. VICKY L. VANVLECK (PRACTICE MANAGER)
(817) 335-8151
Entity
Organization
Contact information
Practice address
1250 8TH AVE, SUITE 135, FORT WORTH, TX 76104
(817) 335-8151
(817) 335-2670
Mailing address
1250 8TH AVE, SUITE 135, FORT WORTH, TX 76104
(817) 335-8151
(817) 335-2670
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
H2007
TX
174400000X
Specialist
L4150
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
031074002
—
TX
05
—
166927701
—
TX
01
—
8G2131
TODD E. SAMUELSON MD BCBS
TX
01
—
H2007
TODD E SAMUELSON MD LICEN
TX
Enumeration date
05/09/2007
Last updated
01/24/2011
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