Healthcare Provider Details

I. General information

NPI: 1003947474
Provider Name (Legal Business Name): CDR PLASTIC SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 LUSITANA ST STE 904
HONOLULU HI
96813-2448
US

IV. Provider business mailing address

4470 SIERRA DR
HONOLULU HI
96816-4022
US

V. Phone/Fax

Practice location:
  • Phone: 808-525-6590
  • Fax: 808-599-8801
Mailing address:
  • Phone: 808-525-6590
  • Fax: 808-599-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD12235
License Number StateHI

VIII. Authorized Official

Name: DR. CARL LEGASPI DE LOS REYES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 808-525-6590