Provider Demographics
NPI:1376559203
Name:WATERFORD, ROBERT RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDOLPH
Last Name:WATERFORD
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 923
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-0923
Mailing Address - Country:US
Mailing Address - Phone:808-268-5789
Mailing Address - Fax:
Practice Address - Street 1:385 HUKILIKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3522
Practice Address - Country:US
Practice Address - Phone:808-871-8346
Practice Address - Fax:808-871-8344
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15055208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBW115YOtherMEDICARE PTAN
HIBW115YOtherMEDICARE PTAN