=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992232037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAROLD NILSSON, M.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2017
-----------------------------------------------------
Last Update Date | 05/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 KAPIOLANI BLVD STE 825
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-941-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 KAPIOLANI BLVD STE 825
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAROLD NILSSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-941-2772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD7520
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------