Provider Demographics
NPI:1356583264
Name:SAMELSON, SCOTT GUSTAV (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:GUSTAV
Last Name:SAMELSON
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 1:10115 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-0324
Mailing Address - Country:US
Mailing Address - Phone:530-386-1701
Mailing Address - Fax:
Practice Address - Street 1:925 NORTH LAKE BLVD
Practice Address - Street 2:
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145
Practice Address - Country:US
Practice Address - Phone:530-581-8864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126885207Q00000X
CO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program