Healthcare Provider Details

I. General information

NPI: 1477636215
Provider Name (Legal Business Name): JORGE CRUZ SAMANIEGO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PUNCHBOWL STREET
HONOLULU HI
96813-2499
US

IV. Provider business mailing address

1177 QUEEN ST APT. # 2306
HONOLULU HI
96814-4138
US

V. Phone/Fax

Practice location:
  • Phone: 808-691-1000
  • Fax:
Mailing address:
  • Phone: 808-224-7211
  • Fax: 808-597-1597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-9469
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD-9469
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-9469
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: