Provider Demographics
NPI:1366763567
Name:HAWK, SAMUEL G (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:HAWK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14326 ROCHESTER ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6266
Mailing Address - Country:US
Mailing Address - Phone:612-486-2226
Mailing Address - Fax:
Practice Address - Street 1:14326 ROCHESTER ST NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-6266
Practice Address - Country:US
Practice Address - Phone:612-486-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1424208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice