Healthcare Provider Details

I. General information

NPI: 1104973908
Provider Name (Legal Business Name): SERGEI TIKHONENKOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST SUITE 602
HONOLULU HI
96813-2429
US

IV. Provider business mailing address

1329 LUSITANA ST SUITE 602
HONOLULU HI
96813-2429
US

V. Phone/Fax

Practice location:
  • Phone: 808-522-5055
  • Fax:
Mailing address:
  • Phone: 808-522-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number40887
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: