Healthcare Provider Details

I. General information

NPI: 1861596264
Provider Name (Legal Business Name): ANTHONY TONGWON GHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 10/02/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15TH MDG 755 SCOTT CIRCLE
JBPH-HICKAM HI
96853
US

IV. Provider business mailing address

15TH MDG 755 SCOTT CIRCLE
JBPH-HICKAM HI
96853
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6776
  • Fax: 808-448-6113
Mailing address:
  • Phone: 808-448-6776
  • Fax: 808-448-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number8924
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8924
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: