Provider Demographics
NPI:1043329832
Name:AU, RUSSELL W L (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W L
Last Name:AU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1480 MOANIANI ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4632
Mailing Address - Country:US
Mailing Address - Phone:808-432-3100
Mailing Address - Fax:
Practice Address - Street 1:94-1480 MOANIANI ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4632
Practice Address - Country:US
Practice Address - Phone:808-432-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-249152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05547201Medicaid
HI0000063883OtherHMSA BILLING NUMBER
HIT91917Medicare UPIN
HI05547201Medicaid