Provider Demographics
NPI:1780061242
Name:SAMUELSON, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-0050
Mailing Address - Country:US
Mailing Address - Phone:541-246-0221
Mailing Address - Fax:
Practice Address - Street 1:581 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3816
Practice Address - Country:US
Practice Address - Phone:541-687-6431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist