Provider Demographics
NPI:1578677019
Name:SAMUELSON, SCOTT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JOHN
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 W 20TH ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-9640
Mailing Address - Country:US
Mailing Address - Phone:970-378-8000
Mailing Address - Fax:
Practice Address - Street 1:473 CASTLE PINES AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-7859
Practice Address - Country:US
Practice Address - Phone:970-587-7881
Practice Address - Fax:970-587-7738
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0035373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000145425Medicaid
CO1353739Medicaid
COCE3148Medicare ID - Type Unspecified