Provider Demographics
NPI:1487645156
Name:SAMUELSON, GREGORY L (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
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 1:401 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-1524
Mailing Address - Country:US
Mailing Address - Phone:712-542-5461
Mailing Address - Fax:
Practice Address - Street 1:116 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-1611
Practice Address - Country:US
Practice Address - Phone:712-542-6513
Practice Address - Fax:712-542-2274
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07428OtherBCBS
1487645156OtherBLOCK VISION
NE100249544-00Medicaid
IA2262956Medicaid
24362OtherMIDLANDS CHOICE
22-00001OtherUHC
IA07423OtherBCBS
930454OtherEYEMED
22-00001OtherUHC
930454OtherEYEMED
IA1309730002Medicare NSC
410041721Medicare PIN
IA07423OtherBCBS
IA2262956Medicaid
P00047566Medicare PIN