Provider Demographics
NPI:1538124979
Name:DERIEG, MARTA L (MD)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:L
Last Name:DERIEG
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 1:76-6225 KUAKINI HWY
Mailing Address - Street 2:STE C101
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3212
Mailing Address - Country:US
Mailing Address - Phone:808-329-7067
Mailing Address - Fax:808-329-2404
Practice Address - Street 1:76-6225 KUAKINI HWY
Practice Address - Street 2:STE C101
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3212
Practice Address - Country:US
Practice Address - Phone:808-329-7067
Practice Address - Fax:808-329-2404
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD10708208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI49585501Medicaid