Healthcare Provider Details

I. General information

NPI: 1891208930
Provider Name (Legal Business Name): PONO PODIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2017
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 KUPUOHI ST STE 204
LAHAINA HI
96761-2714
US

IV. Provider business mailing address

40 KUPUOHI ST STE 204
LAHAINA HI
96761-2714
US

V. Phone/Fax

Practice location:
  • Phone: 808-727-2117
  • Fax: 808-793-2238
Mailing address:
  • Phone: 808-727-2117
  • Fax: 808-793-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO-202
License Number StateHI

VIII. Authorized Official

Name: DR. DAVID WING LEE
Title or Position: OWNER
Credential: DPM
Phone: 808-727-2117