Provider Demographics
NPI:1619071826
Name:SAMUELSON, WILLIAM OLIVER (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:OLIVER
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 1:2800 PIERCE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-224-8677
Mailing Address - Fax:712-277-1662
Practice Address - Street 1:2800 PIERCE ST
Practice Address - Street 2:STE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-224-8677
Practice Address - Fax:712-277-1662
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26070207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00799078OtherMEDICARE RR
IA1155020001Medicare NSC
IAIB1592007Medicare PIN