Provider Demographics
NPI:1003037052
Name:TAVAKOLI, HOMAYON M (MD)
Entity Type:Individual
Prefix:DR
First Name:HOMAYON
Middle Name:M
Last Name:TAVAKOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S. KIHEI RD.
Mailing Address - Street 2:SUITE # 103
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753
Mailing Address - Country:US
Mailing Address - Phone:808-879-7781
Mailing Address - Fax:808-879-0594
Practice Address - Street 1:1325 S. KIHEI RD.
Practice Address - Street 2:SUITE # 103
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753
Practice Address - Country:US
Practice Address - Phone:808-879-7781
Practice Address - Fax:808-879-0594
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7153208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI51101Medicare ID - Type Unspecified
E76785Medicare UPIN