Healthcare Provider Details

I. General information

NPI: 1861443319
Provider Name (Legal Business Name): MARY ANN ANTONELLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 AULIKE ST, #301
KAILUA HI
96734
US

IV. Provider business mailing address

651 ILALO ST MEB 3RD FLOOR
HONOLULU HI
96813-5525
US

V. Phone/Fax

Practice location:
  • Phone: 808-261-8894
  • Fax: 808-261-8894
Mailing address:
  • Phone: 808-692-1000
  • Fax: 808-692-1251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD4592
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: