Healthcare Provider Details

I. General information

NPI: 1417089103
Provider Name (Legal Business Name): TODD H.M. MIRZAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 S BERETANIA ST SUITE 120
HONOLULU HI
96826-1301
US

IV. Provider business mailing address

1907 S BERETANIA ST SUITE 120
HONOLULU HI
96826-1301
US

V. Phone/Fax

Practice location:
  • Phone: 808-952-9779
  • Fax: 808-952-9988
Mailing address:
  • Phone: 808-952-9779
  • Fax: 808-952-9988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD11980
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: