Healthcare Provider Details

I. General information

NPI: 1760239834
Provider Name (Legal Business Name): REEF SHARK PEDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134-1 EAST MARINE CORPS DR.
DEDEDO GU
96929
US

IV. Provider business mailing address

PO BOX 9835
TAMUNING GU
96931-5835
US

V. Phone/Fax

Practice location:
  • Phone: 671-689-8422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL UM
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 671-689-8422