Healthcare Provider Details

I. General information

NPI: 1558545681
Provider Name (Legal Business Name): CUSTOMIZED THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5995 KUAKINI HWY STE 427
KAILUA KONA HI
96740-2123
US

IV. Provider business mailing address

3465 WAIALAE AVE 4TH FLOOR
HONOLULU HI
96816-2650
US

V. Phone/Fax

Practice location:
  • Phone: 808-557-0864
  • Fax: 808-329-3238
Mailing address:
  • Phone: 808-432-9216
  • Fax: 808-533-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberG23749
License Number StateCA

VIII. Authorized Official

Name: OLUWOLE O ODUJINRIN
Title or Position: PRESIDENT
Credential: MD
Phone: 808-557-0864