Healthcare Provider Details

I. General information

NPI: 1891994224
Provider Name (Legal Business Name): SAMUEL HARALDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 W ROSEDALE ST #200
FORT WORTH TX
76104-7437
US

IV. Provider business mailing address

1651 W ROSEDALE ST #200
FORT WORTH TX
76104-7437
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-4316
  • Fax: 817-336-2504
Mailing address:
  • Phone: 817-335-4316
  • Fax: 817-336-2504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL9230
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberL9230
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: