Healthcare Provider Details

I. General information

NPI: 1790789600
Provider Name (Legal Business Name): GALE ROLLAND BEARDSLEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 05/07/2021
Certification Date: 04/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 WILDER AVE APT 704
HONOLULU HI
96822-4666
US

IV. Provider business mailing address

1629 WILDER AVE APT 704
HONOLULU HI
96822-4666
US

V. Phone/Fax

Practice location:
  • Phone: 808-721-7278
  • Fax: 808-207-3799
Mailing address:
  • Phone: 808-721-7278
  • Fax: 808-207-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD4083
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG151697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: