Basic Information
| Provider Information | |||||||||
| NPI: | 1356583264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMELSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | GUSTAV | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10115 W RIVER ST | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961610324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303861701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 NORTH LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | TAHOE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305818864 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A126885 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.