Healthcare Provider Details

I. General information

NPI: 1912413295
Provider Name (Legal Business Name): DAVIS J WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date: 04/13/2024
Reactivation Date: 05/01/2024

III. Provider practice location address

1319 PUNAHOU ST FL 7
HONOLULU HI
96826-1001
US

IV. Provider business mailing address

1319 PUNAHOU ST FL 7
HONOLULU HI
96826-1001
US

V. Phone/Fax

Practice location:
  • Phone: 808-586-2890
  • Fax:
Mailing address:
  • Phone: 808-586-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMDR-8733
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: