Healthcare Provider Details

I. General information

NPI: 1598106247
Provider Name (Legal Business Name): DAMIEN TAVARES MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 03/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 LILIHA ST SUITE 407
HONOLULU HI
96817-1600
US

IV. Provider business mailing address

2226 LILIHA ST SUITE 407
HONOLULU HI
96817-1600
US

V. Phone/Fax

Practice location:
  • Phone: 808-445-9172
  • Fax: 808-445-9182
Mailing address:
  • Phone: 808-445-9172
  • Fax: 808-445-9182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberMD15987
License Number StateHI

VIII. Authorized Official

Name: DR. DAMIEN KEKANEINOA TAVARES III
Title or Position: SOLE MEMBER
Credential: MD
Phone: 808-445-9172