Provider Demographics
NPI:1033394838
Name:GROOM, JED A (MD)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:A
Last Name:GROOM
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 1:64-1066 B MAMALAHOA HWY.
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8425
Mailing Address - Country:US
Mailing Address - Phone:808-885-6006
Mailing Address - Fax:808-885-0906
Practice Address - Street 1:64-1066 MAMALAHOA HWY UNIT B
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7309
Practice Address - Country:US
Practice Address - Phone:808-885-6006
Practice Address - Fax:808-885-0906
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00376101Medicaid
HID36133Medicare UPIN