Healthcare Provider Details

I. General information

NPI: 1891130852
Provider Name (Legal Business Name): ELNUR GAJIEV PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28-1672 OLD MAMALAHOA HWY BACK BUILDING, 2ND FLOOR
HONOMU HI
96728
US

IV. Provider business mailing address

PO BOX 831153
PEPEEKEO HI
96783-1072
US

V. Phone/Fax

Practice location:
  • Phone: 347-602-2596
  • Fax:
Mailing address:
  • Phone: 347-602-2596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: