MEDICARE: INNOVATION MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD13057	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225352966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATION MD LLC

Provider Business Mailing Address
First Line	:	45-1151 KAMEHAMEHA HWY STE C
Second Line	:
City	:	KANEOHE
State	:	HI
Zip	:	96744-3211
Country	:	US
Telephone Number	:	808-247-7770
Fax Number	:	808-247-7799

Provider Business Practice Location Address
First Line	:	45-1151 KAMEHAMEHA HWY STE C
Second Line	:
City	:	KANEOHE
State	:	HI
Zip	:	96744-3211
Country	:	US
Telephone Number	:	808-247-7770
Fax Number	:	808-247-7799

Authorized Official
Title or Position	:	MEDICAL OFFICE MANAGER
Name	:	MRS. ELIZABETH SAMSAMI
Credential	:
Telephone Number	:	808-387-0911

Provider Enumeration Date	:	03/24/2010
Last Update Date	:	02/18/2020

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Directions to “INNOVATION MD LLC ” Practice Location

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