Healthcare Provider Details

I. General information

NPI: 1063572352
Provider Name (Legal Business Name): JOHN EDWARD DEBOARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST SUITE 102
HONOLULU HI
96813-2429
US

IV. Provider business mailing address

1329 LUSITANA ST STE 102
HONOLULU HI
96813-2401
US

V. Phone/Fax

Practice location:
  • Phone: 808-533-4949
  • Fax: 808-536-2224
Mailing address:
  • Phone: 808-533-1020
  • Fax: 808-533-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4978
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: