Provider Demographics
NPI:1902336274
Name:SAMUELSON, ALEXANDRA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 S CLIFF AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6954
Mailing Address - Country:US
Mailing Address - Phone:816-478-1230
Mailing Address - Fax:
Practice Address - Street 1:670 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1653
Practice Address - Country:US
Practice Address - Phone:816-478-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9221T152W00000X
MO2021020008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ00126189OtherRAILROAD MEDICARE