Healthcare Provider Details

I. General information

NPI: 1780750257
Provider Name (Legal Business Name): DANIEL M. STULACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3288 MOANALUA RD
HONOLULU HI
96819-1469
US

IV. Provider business mailing address

3288 MOANALUA RD
HONOLULU HI
96819-1469
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-0000
  • Fax:
Mailing address:
  • Phone: 808-432-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDOS-1122
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number20A 12771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: