Healthcare Provider Details

I. General information

NPI: 1083742878
Provider Name (Legal Business Name): MARY LYNN RICARDO-DUKELOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LILIHA ST
HONOLULU HI
96817-1646
US

IV. Provider business mailing address

PO BOX 25370
HONOLULU HI
96825-0370
US

V. Phone/Fax

Practice location:
  • Phone: 808-772-2217
  • Fax:
Mailing address:
  • Phone: 808-536-0314
  • Fax: 808-536-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number13253
License Number StateHI

VIII. Authorized Official

Name: MARY LYNN RICARDO-DUKELOW
Title or Position: OWNER
Credential: M.D.
Phone: 808-772-2217