Healthcare Provider Details

I. General information

NPI: 1255400370
Provider Name (Legal Business Name): LAURA D. PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 S BERETANIA ST SUITE 501
HONOLULU HI
96826-1301
US

IV. Provider business mailing address

1907 S BERETANIA ST SUITE 501
HONOLULU HI
96826-1301
US

V. Phone/Fax

Practice location:
  • Phone: 808-949-3444
  • Fax: 808-949-7808
Mailing address:
  • Phone: 808-949-3444
  • Fax: 808-949-7808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD-12588
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: