Provider Demographics
NPI:1558386243
Name:GUTERMUTH, KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:GUTERMUTH
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 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1666
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:808-573-9240
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1666
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-573-9240
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD11686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI99017685996793B028OtherTRICARE
HI990176859OtherHMAA - HMA - HMS
HIA231074OtherHMSA-65CP-HMSA QUEST
HI50087802OtherALOHA CARE QUEST
HI50087802Medicaid
HI598743OtherUHA
HI99017685996793B028OtherTRICARE
HI50087802OtherALOHA CARE QUEST
HI50087802Medicaid