Provider Demographics
NPI:1205840469
Name:MAURO, CHARLES THOMAS IV (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:MAURO
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 ULULANI ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3913
Mailing Address - Country:US
Mailing Address - Phone:808-961-3427
Mailing Address - Fax:
Practice Address - Street 1:868 ULULANI ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3913
Practice Address - Country:US
Practice Address - Phone:808-961-3427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12734207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI12D1029385OtherCLIA NUMBER
HI12D1029385OtherCLIA NUMBER
HI12D1029385OtherCLIA NUMBER
HII03851Medicare UPIN