Healthcare Provider Details

I. General information

NPI: 1780693267
Provider Name (Legal Business Name): RUSSELL WONG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N KUAKINI ST STE 811
HONOLULU HI
96817-2362
US

IV. Provider business mailing address

PO BOX 25370
HONOLULU HI
96825-0370
US

V. Phone/Fax

Practice location:
  • Phone: 808-531-2731
  • Fax:
Mailing address:
  • Phone: 808-536-0300
  • Fax: 808-536-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number7430
License Number StateHI

VIII. Authorized Official

Name: RUSSELL WONG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 808-531-2731