Healthcare Provider Details

I. General information

NPI: 1861473233
Provider Name (Legal Business Name): BENJAMIN TIONGSON GAMBOA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 02/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 S WAKEA AVE STE 107
KAHULUI HI
96732-1385
US

IV. Provider business mailing address

135 S WAKEA AVE STE 107
KAHULUI HI
96732-1385
US

V. Phone/Fax

Practice location:
  • Phone: 808-873-0299
  • Fax: 808-873-0290
Mailing address:
  • Phone: 808-873-0299
  • Fax: 808-873-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberHD8771
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: