Healthcare Provider Details

I. General information

NPI: 1477741726
Provider Name (Legal Business Name): MANKWAN T WONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 KALAKAUA AVE STE 108
HONOLULU HI
96826-3700
US

IV. Provider business mailing address

1750 KALAKAUA AVE STE 108
HONOLULU HI
96826-3700
US

V. Phone/Fax

Practice location:
  • Phone: 808-942-8727
  • Fax: 808-948-9649
Mailing address:
  • Phone: 808-942-8727
  • Fax: 808-948-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number11859
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number11859
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: