Healthcare Provider Details

I. General information

NPI: 1639263114
Provider Name (Legal Business Name): KENNETH D. DOUGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3288 MOANALUA RD
HONOLULU HI
96819-1469
US

IV. Provider business mailing address

3288 MOANALUA RD
HONOLULU HI
96819-1469
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-0000
  • Fax:
Mailing address:
  • Phone: 808-432-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-6817
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: