Healthcare Provider Details

I. General information

NPI: 1053480152
Provider Name (Legal Business Name): JON FAIRFAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 S KING ST SUITE 325
HONOLULU HI
96814-2008
US

IV. Provider business mailing address

1350 S KING ST SUITE 325
HONOLULU HI
96814-2008
US

V. Phone/Fax

Practice location:
  • Phone: 808-591-9116
  • Fax: 808-591-9655
Mailing address:
  • Phone: 808-591-9116
  • Fax: 808-591-9655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD7739
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: