Provider Demographics
NPI:1477616449
Name:WOLFSON, SAMUEL F (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:F
Last Name:WOLFSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9905 45TH AVENUE NORTH
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-3315
Mailing Address - Country:US
Mailing Address - Phone:763-595-8414
Mailing Address - Fax:763-595-8438
Practice Address - Street 1:9905 45TH AVENUE NORTH
Practice Address - Street 2:SUITE 110
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-3315
Practice Address - Country:US
Practice Address - Phone:763-595-8414
Practice Address - Fax:763-595-8438
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0909390001OtherDMERC
MN102877OtherUCARE MINNESOTA
MN2499537OtherMETROPOLITAN HEALTH PLAN
FM410038901OtherRAILROAD MEDICARE
MN23979OtherHEALTH PARTNERS
MN2200080OtherMEDICA PRIMARY
MN0909390001OtherADMINISTAR FEDERAL
MN19467W0OtherBLUE CROSS BLUE SHIELD
FM2202766OtherMEDICA CHOICE
MN315023200Medicaid
MN2499537OtherMETROPOLITAN HEALTH PLAN