Provider Demographics
NPI:1477864429
Name:BLACK, BRANDEE S (MD)
Entity Type:Individual
Prefix:
First Name:BRANDEE
Middle Name:S
Last Name:BLACK
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 1:30 AULIKE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2750
Mailing Address - Country:US
Mailing Address - Phone:808-261-4658
Mailing Address - Fax:808-263-2036
Practice Address - Street 1:30 AULIKE ST STE 201
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2750
Practice Address - Country:US
Practice Address - Phone:505-933-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0520207XX0005X
HI19841207XX0005X
CODR.0060743207XX0005X
WAMD61425913207XX0005X
ORMD207442207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2231259Medicaid