Healthcare Provider Details

I. General information

NPI: 1215085576
Provider Name (Legal Business Name): DOUGLAS M COOPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MAHALANI ST.
WAILUKU HI
96793
US

IV. Provider business mailing address

275 ULUMALU RD.
HAIKU HI
96708
US

V. Phone/Fax

Practice location:
  • Phone: 808-984-2150
  • Fax: 808-984-2155
Mailing address:
  • Phone: 808-258-1965
  • Fax: 808-984-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD-2108
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: