Provider Demographics
NPI:1669491858
Name:JOHNSEN, SAMUEL ERNEST WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ERNEST WILLIAM
Last Name:JOHNSEN
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 1:180 DICKENSON ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-1215
Mailing Address - Country:US
Mailing Address - Phone:808-214-5985
Mailing Address - Fax:808-214-6766
Practice Address - Street 1:180 DICKENSON ST STE 103
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-1215
Practice Address - Country:US
Practice Address - Phone:808-214-5985
Practice Address - Fax:808-214-6766
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI824532282OtherUHA
HI824532282OtherHMAA
HI00C0241160OtherHMSA
HI824532282OtherHMA
HI824532282Medicaid
HI53638602Medicaid
HI53638601Medicaid
HIH55619Medicare PIN