=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841563533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUDOC PEDIATRICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2012
-----------------------------------------------------
Last Update Date | 02/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95-993 UKUWAI ST #2602
-----------------------------------------------------
City | MILILANI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96789-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-722-8792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95-993 UKUWAI ST #2602
-----------------------------------------------------
City | MILILANI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96789-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TOYIN AJOSE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-722-8792
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number | MD 14643
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------