Provider Demographics
NPI:1275519290
Name:SAMUELSON, STEVEN (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:428 W. MAIN STREET
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-0350
Mailing Address - Country:US
Mailing Address - Phone:608-437-3377
Mailing Address - Fax:608-437-5063
Practice Address - Street 1:428 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1902
Practice Address - Country:US
Practice Address - Phone:608-437-3377
Practice Address - Fax:608-437-5063
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38595200Medicaid
WIU56890Medicare UPIN