Healthcare Provider Details

I. General information

NPI: 1619276177
Provider Name (Legal Business Name): JASON W. SUSZKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 PENSACOLA ST
HONOLULU HI
96814-2118
US

IV. Provider business mailing address

1010 PENSACOLA ST
HONOLULU HI
96814-2118
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-2000
  • Fax:
Mailing address:
  • Phone: 808-432-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number15757
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD-19180
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD176186
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: