Healthcare Provider Details

I. General information

NPI: 1922550987
Provider Name (Legal Business Name): AMY REISENAUER MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N HOLOPONO ST STE 215
KIHEI HI
96753-6945
US

IV. Provider business mailing address

1300 N HOLOPONO ST STE 215
KIHEI HI
96753-6945
US

V. Phone/Fax

Practice location:
  • Phone: 808-874-3444
  • Fax:
Mailing address:
  • Phone: 808-874-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD13436
License Number StateHI

VIII. Authorized Official

Name: AMY KERSTEN REISENAUER
Title or Position: OWNER
Credential: M.D.
Phone: 808-874-3444