Provider Demographics
NPI:1235481185
Name:ISLAND UROLOGY OAHU LLC
Entity Type:Organization
Organization Name:ISLAND UROLOGY OAHU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:TIKHONENKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-522-5055
Mailing Address - Street 1:1329 LUSITANA ST STE 602
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2431
Mailing Address - Country:US
Mailing Address - Phone:808-522-5055
Mailing Address - Fax:808-524-6306
Practice Address - Street 1:1329 LUSITANA ST STE 602
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2431
Practice Address - Country:US
Practice Address - Phone:808-522-5055
Practice Address - Fax:808-524-6306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-14871208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty