Healthcare Provider Details

I. General information

NPI: 1679707103
Provider Name (Legal Business Name): DERYLL U AMBROCIO MD INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST SUITE 804
HONOLULU HI
96813-2429
US

IV. Provider business mailing address

1329 LUSITANA ST SUITE 804
HONOLULU HI
96813-2429
US

V. Phone/Fax

Practice location:
  • Phone: 808-531-7111
  • Fax: 808-528-5507
Mailing address:
  • Phone: 808-531-7111
  • Fax: 808-528-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD-15066
License Number StateHI

VIII. Authorized Official

Name: DR. DERYLL ULEP AMBROCIO
Title or Position: PRESIDENT
Credential: MD
Phone: 808-531-7111