Healthcare Provider Details

I. General information

NPI: 1760512966
Provider Name (Legal Business Name): BLAKE ANDREW SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PUNCHBOWL ST
HONOLULU HI
96813-2402
US

IV. Provider business mailing address

770 KAPIOLANI BLVD STE 705
HONOLULU HI
96813-5241
US

V. Phone/Fax

Practice location:
  • Phone: 808-547-4311
  • Fax:
Mailing address:
  • Phone: 808-597-8791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number134234
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15211
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: