Provider Demographics
NPI:1497226054
Name:ISLAND DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ISLAND DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:208-640-3504
Mailing Address - Street 1:PO BOX 2279
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-2279
Mailing Address - Country:US
Mailing Address - Phone:808-323-2608
Mailing Address - Fax:808-885-9793
Practice Address - Street 1:75-5995 KUAKINI HWY STE 443&445
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2144
Practice Address - Country:US
Practice Address - Phone:808-323-2608
Practice Address - Fax:808-885-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty