Provider Demographics
NPI:1366825655
Name:DIRECT DERMATOLOGY PROFESSIONALS HAWAII PC
Entity Type:Organization
Organization Name:DIRECT DERMATOLOGY PROFESSIONALS HAWAII PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-944-7546
Mailing Address - Street 1:530 LYTTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1541
Mailing Address - Country:US
Mailing Address - Phone:855-944-7546
Mailing Address - Fax:
Practice Address - Street 1:1380 LUSITANA ST STE 814
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2444
Practice Address - Country:US
Practice Address - Phone:855-944-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-04
Last Update Date:2015-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty