Healthcare Provider Details

I. General information

NPI: 1356341002
Provider Name (Legal Business Name): RUSSELL G TACATA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 LILIHA STREET #3
HONOLULU HI
96817-3152
US

IV. Provider business mailing address

1619 LILIHA STREET #3
HONOLULU HI
96817-3152
US

V. Phone/Fax

Practice location:
  • Phone: 808-531-5454
  • Fax: 808-531-5451
Mailing address:
  • Phone: 808-531-5454
  • Fax: 808-531-5451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9570
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: