Healthcare Provider Details

I. General information

NPI: 1477864429
Provider Name (Legal Business Name): BRANDEE S BLACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 AULIKE ST STE 201
KAILUA HI
96734-2750
US

IV. Provider business mailing address

30 AULIKE ST STE 201
KAILUA HI
96734-2750
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-4424
  • Fax:
Mailing address:
  • Phone: 808-261-4658
  • Fax: 808-263-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD2015-0520
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number19841
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberDR.0060743
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD61425913
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD207442
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: