Healthcare Provider Details

I. General information

NPI: 1134759715
Provider Name (Legal Business Name): DAVID MALDONADO SANTIAGO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAVID MALDONADO IDC

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 04/08/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
JBPHH HI
96860-4908
US

IV. Provider business mailing address

1020 KAKALA ST APT 1306
KAPOLEI HI
96707-4547
US

V. Phone/Fax

Practice location:
  • Phone: 808-473-1880
  • Fax:
Mailing address:
  • Phone: 224-772-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: