Provider Demographics
NPI:1558310383
Name:DIDOMIZIO, DANIEL (PA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:DIDOMIZIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 RAILROAD AVE
Mailing Address - Street 2:STE A-3
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720
Mailing Address - Country:US
Mailing Address - Phone:808-969-9220
Mailing Address - Fax:808-961-4794
Practice Address - Street 1:45 MOHOULI ST.
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720
Practice Address - Country:US
Practice Address - Phone:808-935-8484
Practice Address - Fax:808-961-6710
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD84363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMD0516421OtherDEA
HIS62819Medicare UPIN