Provider Demographics
NPI:1154986024
Name:ANTHONY, SAMUEL JESSE II (DO)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JESSE
Last Name:ANTHONY
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20515 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 FAIRVIEW AVE N STE 145
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2710
Practice Address - Country:US
Practice Address - Phone:888-290-1209
Practice Address - Fax:833-973-3529
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN76012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty