Provider Demographics
NPI:1962708503
Name:SAMSON, BRUCE MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:MICHAEL
Last Name:SAMSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13234 FAWN DR
Mailing Address - Street 2:
Mailing Address - City:OSAKIS
Mailing Address - State:MN
Mailing Address - Zip Code:56360-4858
Mailing Address - Country:US
Mailing Address - Phone:952-240-9298
Mailing Address - Fax:952-955-1970
Practice Address - Street 1:13234 FAWN DR
Practice Address - Street 2:
Practice Address - City:OSAKIS
Practice Address - State:MN
Practice Address - Zip Code:56360-4858
Practice Address - Country:US
Practice Address - Phone:952-240-9298
Practice Address - Fax:952-955-1970
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-30
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN023083208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice