Healthcare Provider Details

I. General information

NPI: 1649477167
Provider Name (Legal Business Name): JAIME WONG-LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAIME WONG-DOMINGUEZ MD

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

IV. Provider business mailing address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

V. Phone/Fax

Practice location:
  • Phone: 808-474-4242
  • Fax: 808-471-0918
Mailing address:
  • Phone: 808-474-4242
  • Fax: 808-471-0918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101246156
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101246156
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: