Healthcare Provider Details

I. General information

NPI: 1023342169
Provider Name (Legal Business Name): ROBERT D IRVINE, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PONAHAWAI ST STE 115
HILO HI
96720-2660
US

IV. Provider business mailing address

670 PONAHAWAI ST STE 115
HILO HI
96720-2660
US

V. Phone/Fax

Practice location:
  • Phone: 808-935-5465
  • Fax: 808-935-5467
Mailing address:
  • Phone: 808-935-5465
  • Fax: 808-935-5467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD2284
License Number StateHI

VIII. Authorized Official

Name: ROBERT DAILEY IRVINE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 808-935-5465