Provider Demographics
NPI:1508938069
Name:REYES, PHILLIP WAIHOLO (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WAIHOLO
Last Name:REYES
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 1:5567 POOLA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1561
Mailing Address - Country:US
Mailing Address - Phone:808-373-4809
Mailing Address - Fax:
Practice Address - Street 1:39 ALA MALAMA
Practice Address - Street 2:
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748
Practice Address - Country:US
Practice Address - Phone:808-553-5353
Practice Address - Fax:808-553-4269
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-6127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI055912-01Medicaid
HI055912-01Medicaid
HI0000BDTDNMedicare ID - Type Unspecified