Provider Demographics
NPI:1275510653
Name:BROGGINI, RAY E (MD)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:E
Last Name:BROGGINI
Suffix:
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-0012
Mailing Address - Country:US
Mailing Address - Phone:808-775-1051
Mailing Address - Fax:808-775-1051
Practice Address - Street 1:45-549 PLUMERIA ST
Practice Address - Street 2:HAMAKUA HEALTH CENTER INC
Practice Address - City:HONOKAA
Practice Address - State:HI
Practice Address - Zip Code:96727-6902
Practice Address - Country:US
Practice Address - Phone:808-775-7204
Practice Address - Fax:808-775-9404
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12192207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
121813OtherMEDICARE FQHC
HI51864901Medicaid
HI51864901Medicaid
HHCMedicare ID - Type Unspecified