Healthcare Provider Details

I. General information

NPI: 1518374644
Provider Name (Legal Business Name): WILLIAM OLIVER SAMUELSON IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 N SIOUX POINT ROAD
DAKOTA DUNES SD
57049-5312
US

IV. Provider business mailing address

575 N SIOUX POINT ROAD
DAKOTA DUNES SD
57049-5312
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-2667
  • Fax: 605-217-2900
Mailing address:
  • Phone: 605-217-2667
  • Fax: 605-217-2900

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number60328
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number32965
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD-47819
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number12307
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: