Provider Demographics
NPI:1457465577
Name:WORTMANN, ERIC WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WILLIAM
Last Name:WORTMANN
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 1:3994 PAI ST
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-9592
Mailing Address - Country:US
Mailing Address - Phone:808-332-6314
Mailing Address - Fax:808-332-6314
Practice Address - Street 1:3994 PAI ST
Practice Address - Street 2:
Practice Address - City:KALAHEO
Practice Address - State:HI
Practice Address - Zip Code:96741-9592
Practice Address - Country:US
Practice Address - Phone:808-332-6314
Practice Address - Fax:808-332-6314
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI8883207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04482401Medicaid
HI04482401Medicaid