Healthcare Provider Details

I. General information

NPI: 1184600504
Provider Name (Legal Business Name): TAD IWANUMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2005
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N KUAKINI ST 703
HONOLULU HI
96817-2364
US

IV. Provider business mailing address

321 N KUAKINI ST 703
HONOLULU HI
96817-2364
US

V. Phone/Fax

Practice location:
  • Phone: 808-524-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2484
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: