Healthcare Provider Details

I. General information

NPI: 1861588261
Provider Name (Legal Business Name): KEVIN WAYNE DIEFFENBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-1247 KAAHUMANU ST SUITE 109
AIEA HI
96701-5311
US

IV. Provider business mailing address

98-1247 KAAHUMANU ST SUITE 109
AIEA HI
96701-5311
US

V. Phone/Fax

Practice location:
  • Phone: 808-678-1955
  • Fax: 808-678-1081
Mailing address:
  • Phone: 808-678-1955
  • Fax: 808-678-1081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number8242
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: