Provider Demographics
NPI:1093070674
Name:ANTONINO, AMANDA A (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:A
Last Name:ANTONINO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4-901 KUHIO HWY
Mailing Address - Street 2:STE. B
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1576
Mailing Address - Country:US
Mailing Address - Phone:808-822-3733
Mailing Address - Fax:
Practice Address - Street 1:4-901 KUHIO HWY
Practice Address - Street 2:STE. B
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1576
Practice Address - Country:US
Practice Address - Phone:808-822-3733
Practice Address - Fax:808-822-7355
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI772152W00000X
NV735152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIHF846ZMedicare PIN