Provider Demographics
NPI:1447211842
Name:TROCKMAN, GORDON J (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:J
Last Name:TROCKMAN
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 1:354 ULUNIU STREET
Mailing Address - Street 2:SUITE 410
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2534
Mailing Address - Country:US
Mailing Address - Phone:808-263-9488
Mailing Address - Fax:808-262-5479
Practice Address - Street 1:354 ULUNIU STREET
Practice Address - Street 2:SUITE 410
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2534
Practice Address - Country:US
Practice Address - Phone:808-263-9488
Practice Address - Fax:808-262-5479
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD29802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03754201Medicaid
0000041319OtherHMSA
HI0000041319OtherHMSA
HI00B0041315OtherHMSA
HI03754202Medicaid
HIH100042Medicare ID - Type Unspecified
HI03754202Medicaid