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General NPI Number Information
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NPI Number | 1134667603
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Entity Type | Organization
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Legal Business Name | HONOLULU DERMATOLOGY LLC
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Dates
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Enumeration Date | 02/06/2017
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 1953 S BERETANIA ST SUITE 3C
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City | HONOLULU
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State | HI
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Zip | 96826-1300
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Country | US
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Telephone | 808-670-3333
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Fax | 808-447-8715
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Provider Business Mailing Address
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Address Line | PO BOX 11736
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City | HONOLULU
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State | HI
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Zip | 96828-0736
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Country | US
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Telephone | 808-670-3333
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Fax | 808-447-8715
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Authorized Official
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Title or Position | MANAGER
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Name | SHAD MICHAEL GILL
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Credential |
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Telephone | 808-670-3333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 18537
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License Number State | HI
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