Provider Demographics
NPI:1134667603
Name:HONOLULU DERMATOLOGY LLC
Entity Type:Organization
Organization Name:HONOLULU DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-670-3333
Mailing Address - Street 1:PO BOX 11736
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96828-0736
Mailing Address - Country:US
Mailing Address - Phone:808-670-3333
Mailing Address - Fax:808-447-8715
Practice Address - Street 1:1953 S BERETANIA ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1300
Practice Address - Country:US
Practice Address - Phone:808-670-3333
Practice Address - Fax:808-447-8715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI18537207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty