Provider Demographics
NPI:1275637712
Name:MADAMBA, JOSE M (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:MADAMBA
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 1:1712 LILIHA ST STE 203
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3100
Mailing Address - Country:US
Mailing Address - Phone:808-523-1355
Mailing Address - Fax:808-537-4139
Practice Address - Street 1:1712 LILIHA ST STE 203
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3100
Practice Address - Country:US
Practice Address - Phone:808-523-1355
Practice Address - Fax:808-537-4139
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2920208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000040394OtherBCBS OF HAWAII (HMSA)
HI03667301Medicaid
HID43588Medicare UPIN
HI03667301Medicaid