Provider Demographics
NPI:1093342685
Name:CARBULLIDO, CHRISTOPHER PAUL MCDONALD (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER PAUL
Middle Name:MCDONALD
Last Name:CARBULLIDO
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99-905 AIEA HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98-1005 MOANALUA RD SPC 3030
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4735
Practice Address - Country:US
Practice Address - Phone:808-627-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
HIDOSR-563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program