Healthcare Provider Details

I. General information

NPI: 1760612329
Provider Name (Legal Business Name): SUSAN MIKAMI MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WARD AVE SUITE 810
HONOLULU HI
96814-1600
US

IV. Provider business mailing address

PO BOX 10012
HONOLULU HI
96816-0012
US

V. Phone/Fax

Practice location:
  • Phone: 808-351-1012
  • Fax:
Mailing address:
  • Phone: 808-351-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13933
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13933
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number13933
License Number StateHI

VIII. Authorized Official

Name: DR. SUSAN MIKAMI
Title or Position: AGENT
Credential: M.D.
Phone: 808-351-1012