Provider Demographics
NPI:1154735850
Name:HAKEN, SAMANTHA J (MD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:HAKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 N WEST BAYSHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PESHAWBESTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:49682
Mailing Address - Country:US
Mailing Address - Phone:231-534-7750
Mailing Address - Fax:
Practice Address - Street 1:2300 N STALLMAN ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:PESHAWBESTOWN
Practice Address - State:MI
Practice Address - Zip Code:49682
Practice Address - Country:US
Practice Address - Phone:231-534-7200
Practice Address - Fax:231-534-7460
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine