Healthcare Provider Details

I. General information

NPI: 1891310355
Provider Name (Legal Business Name): HAWAIIAN ISLANDS DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 KEOLU DR STE 107
KAILUA HI
96734-3800
US

IV. Provider business mailing address

1051 KEOLU DR STE 107
KAILUA HI
96734-3800
US

V. Phone/Fax

Practice location:
  • Phone: 808-263-3233
  • Fax: 808-263-3220
Mailing address:
  • Phone: 808-263-3233
  • Fax: 808-263-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMI BLACK
Title or Position: OFFICE MANAGER
Credential:
Phone: 808-263-3233