Healthcare Provider Details

I. General information

NPI: 1598984403
Provider Name (Legal Business Name): STEFANIE PARK MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 N KUAKINI ST
HONOLULU HI
96817-2336
US

IV. Provider business mailing address

PO BOX 25490
HONOLULU HI
96825-0490
US

V. Phone/Fax

Practice location:
  • Phone: 808-536-0300
  • Fax: 808-536-0320
Mailing address:
  • Phone: 808-536-0314
  • Fax: 808-536-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14109
License Number StateHI

VIII. Authorized Official

Name: STEFANIE M PARK
Title or Position: OWNER
Credential: MD
Phone: 808-753-1686