Healthcare Provider Details

I. General information

NPI: 1093194912
Provider Name (Legal Business Name): SAMIM GIOTIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 CLEARFORK MAIN ST
FORT WORTH TX
76109-3559
US

IV. Provider business mailing address

5450 CLEARFORK MAIN ST STE 300
FORT WORTH TX
76109-3514
US

V. Phone/Fax

Practice location:
  • Phone: 817-984-1688
  • Fax: 817-419-4494
Mailing address:
  • Phone: 817-334-1400
  • Fax: 817-334-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10054194
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3087
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: