Healthcare Provider Details

I. General information

NPI: 1356583264
Provider Name (Legal Business Name): SCOTT GUSTAV SAMELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 NORTH LAKE BLVD
TAHOE CITY CA
96145
US

IV. Provider business mailing address

3190 FABIAN WAY
TAHOE CITY CA
96145-2032
US

V. Phone/Fax

Practice location:
  • Phone: 530-581-8864
  • Fax:
Mailing address:
  • Phone: 530-386-1701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA126885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: