Healthcare Provider Details

I. General information

NPI: 1588843502
Provider Name (Legal Business Name): KAILUA DERMATOLOGY CENTERS OF HAWAII, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 02/14/2018
Certification Date:
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 TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number10836
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD536
License Number StateHI

VIII. Authorized Official

Name: DOUGLAS M WILLIAMS
Title or Position: OWNER/PHYSICIAN ASSISTANT
Credential: PHYSICIAN ASSISTANT
Phone: 808-263-3233