Provider Demographics
NPI:1114523834
Name:SAMONSKY, MARK (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SAMONSKY
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:HONOMU
Mailing Address - State:HI
Mailing Address - Zip Code:96728-0128
Mailing Address - Country:US
Mailing Address - Phone:808-936-5391
Mailing Address - Fax:
Practice Address - Street 1:556 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2522
Practice Address - Country:US
Practice Address - Phone:808-313-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2000002024207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine