Provider Demographics
NPI:1568408094
Name:WIDHOLM, ANDREW THOMAS
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:THOMAS
Last Name:WIDHOLM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 DAIRY RD
Mailing Address - Street 2:SUITE E233
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2348
Mailing Address - Country:US
Mailing Address - Phone:808-298-1802
Mailing Address - Fax:
Practice Address - Street 1:1360 S BERETANIA ST
Practice Address - Street 2:#215
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1520
Practice Address - Country:US
Practice Address - Phone:808-532-3711
Practice Address - Fax:808-532-3713
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS788207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
002726-01OtherACS
00A0213387OtherHMSA
A020OtherCHAMPUS TRICARE
002726-01OtherACS
H51693Medicare ID - Type Unspecified
050072816Medicare ID - Type Unspecified