Provider Demographics
NPI:1548753122
Name:ZIEGLER, SAMANTHA (OD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ZIEGLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13195 WEAVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-9410
Mailing Address - Country:US
Mailing Address - Phone:767-342-0511
Mailing Address - Fax:763-420-6957
Practice Address - Street 1:13195 WEAVER LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-9410
Practice Address - Country:US
Practice Address - Phone:767-342-0511
Practice Address - Fax:763-420-6957
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3562152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3562OtherMINNESOTA LICENSE