=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487645156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY L SAMUELSON O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 08/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 E WASHINGTON ST
-----------------------------------------------------
City | CLARINDA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51632-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-542-6513
-----------------------------------------------------
Fax | 712-542-2274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N 18TH ST
-----------------------------------------------------
City | CLARINDA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51632-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-542-5461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 01841
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------