Provider Demographics
NPI:1164446050
Name:PEDERSON, JONATHAN (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 ULUHAKU ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4411
Mailing Address - Country:US
Mailing Address - Phone:602-316-9469
Mailing Address - Fax:
Practice Address - Street 1:580 ULUHAKU ST
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4411
Practice Address - Country:US
Practice Address - Phone:602-316-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS 1119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000OtherUPN