Healthcare Provider Details

I. General information

NPI: 1811199417
Provider Name (Legal Business Name): SUSANNAH KERR MISTR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68-1845 WAIKOLOA RD SUITE 218
WAIKOLOA HI
96738-5584
US

IV. Provider business mailing address

PO BOX 383147
WAIKOLOA HI
96738-3147
US

V. Phone/Fax

Practice location:
  • Phone: 808-883-3767
  • Fax:
Mailing address:
  • Phone: 808-883-3767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD 15669
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: