Healthcare Provider Details

I. General information

NPI: 1053056473
Provider Name (Legal Business Name): DANIELLE MARIE MATHISEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PUNAHOU ST STE 824
HONOLULU HI
96826-1032
US

IV. Provider business mailing address

4620 FOXFIRE WAY
FORT WORTH TX
76133-6232
US

V. Phone/Fax

Practice location:
  • Phone: 808-203-6518
  • Fax:
Mailing address:
  • Phone: 817-980-8875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMDR-8280
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMDR-8280
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: