=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538125828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WGH PATHOLOGISTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 12/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 LEHUA ST LABORATORY
-----------------------------------------------------
City | WAHIAWA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-621-4354
-----------------------------------------------------
Fax | 808-621-4457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1585 KAPIOLANI BLVD SUITE 1800
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CLIFFORD C. WONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-621-4354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------