Healthcare Provider Details

I. General information

NPI: 1619467347
Provider Name (Legal Business Name): HAWAII PAIN AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 AULIKE ST STE 411
KAILUA HI
96734-2757
US

IV. Provider business mailing address

1670 MAKALOA ST # 204-321
HONOLULU HI
96814-3232
US

V. Phone/Fax

Practice location:
  • Phone: 808-452-1379
  • Fax: 808-201-4961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number19566
License Number StateHI

VIII. Authorized Official

Name: JONATHAN D CARLSON
Title or Position: MD
Credential: MD
Phone: 808-452-1379