Provider Demographics
NPI:1033177605
Name:KILLEBREW, DARREL WAYN (DO)
Entity Type:Individual
Prefix:DR
First Name:DARREL
Middle Name:WAYN
Last Name:KILLEBREW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15021 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 KAMANI STREET
Practice Address - Street 2:
Practice Address - City:PAHALA
Practice Address - State:HI
Practice Address - Zip Code:96777
Practice Address - Country:US
Practice Address - Phone:808-928-2050
Practice Address - Fax:808-928-8980
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-376207P00000X
AZ2066207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI263681OtherHMSA
HI58799101Medicaid
HI58799101Medicaid