Healthcare Provider Details

I. General information

NPI: 1104927110
Provider Name (Legal Business Name): AMY K REISENAUER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/30/2019
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: 808-874-3443
Mailing address:
  • Phone: 808-874-3444
  • Fax: 808-874-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD-13436
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: