Healthcare Provider Details

I. General information

NPI: 1235481185
Provider Name (Legal Business Name): ISLAND UROLOGY OAHU LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 LUSITANA ST STE 602
HONOLULU HI
96813-2431
US

IV. Provider business mailing address

1329 LUSITANA ST STE 602
HONOLULU HI
96813-2431
US

V. Phone/Fax

Practice location:
  • Phone: 808-522-5055
  • Fax: 808-524-6306
Mailing address:
  • Phone: 808-522-5055
  • Fax: 808-524-6306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD-14871
License Number StateHI

VIII. Authorized Official

Name: SERGEI TIKHONENKOV
Title or Position: OWNER
Credential: M.D.
Phone: 808-522-5055