Healthcare Provider Details

I. General information

NPI: 1740423151
Provider Name (Legal Business Name): DOUGLAS BROOK IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SCOTT CIR
JBPHH HI
96853-5399
US

IV. Provider business mailing address

1603 FOX BLVD
HONOLULU HI
96818-4708
US

V. Phone/Fax

Practice location:
  • Phone: 850-420-3191
  • Fax:
Mailing address:
  • Phone: 850-420-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: