Provider Demographics
NPI:1467413740
Name:WITHY, KELLEY M (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:WITHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-390 KUAHELANI AVE
Mailing Address - Street 2:
Mailing Address - City:MILILANIA
Mailing Address - State:HI
Mailing Address - Zip Code:96789
Mailing Address - Country:US
Mailing Address - Phone:808-627-3200
Mailing Address - Fax:
Practice Address - Street 1:95-390 KUAHELANI AVE
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789
Practice Address - Country:US
Practice Address - Phone:808-627-3200
Practice Address - Fax:808-623-7872
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD8743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07866001Medicaid
HIE207448OtherHMSA
HI07866001Medicaid
HI8FCZWMedicare ID - Type Unspecified