Healthcare Provider Details

I. General information

NPI: 1134330491
Provider Name (Legal Business Name): MARK DAVID NISHIHARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-1079 MOANALUA RD SUITE 500
AIEA HI
96701-4713
US

IV. Provider business mailing address

98-1079 MOANALUA RD SUITE 500
AIEA HI
96701-4713
US

V. Phone/Fax

Practice location:
  • Phone: 808-488-0990
  • Fax: 808-486-4696
Mailing address:
  • Phone: 808-488-0990
  • Fax: 808-486-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD15074
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: