Healthcare Provider Details

I. General information

NPI: 1518347939
Provider Name (Legal Business Name): JOHN DOAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 IANA ST
KAILUA HI
96734-3411
US

IV. Provider business mailing address

23D MEDICAL GROUP 3278 MITCHELL BLVD
MOODY AFB GA
31699-1500
US

V. Phone/Fax

Practice location:
  • Phone: 850-460-5654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDOS-2279
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number076976
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number076976
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: