Provider Demographics
NPI:1083723910
Name:FORTUNATO V. ELIZAGA M.D., INC
Entity Type:Organization
Organization Name:FORTUNATO V. ELIZAGA M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIEVA
Authorized Official - Middle Name:G
Authorized Official - Last Name:ELIZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-524-1144
Mailing Address - Street 1:1712 LILIHA ST STE 306
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3114
Mailing Address - Country:US
Mailing Address - Phone:808-524-1144
Mailing Address - Fax:
Practice Address - Street 1:1712 LILIHA ST
Practice Address - Street 2:SUITE 306
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-5410
Practice Address - Country:US
Practice Address - Phone:808-524-1144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03406601Medicaid
HI0000BDDKVMedicare ID - Type Unspecified
HIE59082Medicare UPIN