Healthcare Provider Details

I. General information

NPI: 1093070674
Provider Name (Legal Business Name): AMANDA A ANTONINO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 10/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4-901 KUHIO HWY STE. B
KAPAA HI
96746-1576
US

IV. Provider business mailing address

4-901 KUHIO HWY STE. B
KAPAA HI
96746-1576
US

V. Phone/Fax

Practice location:
  • Phone: 808-822-3733
  • Fax: 808-822-7355
Mailing address:
  • Phone: 808-822-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number772
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number735
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: