Provider Demographics
NPI:1588612147
Name:VICENTI, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:VICENTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 AULIKE ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2758
Mailing Address - Country:US
Mailing Address - Phone:808-261-3000
Mailing Address - Fax:808-261-3303
Practice Address - Street 1:40 AULIKE ST
Practice Address - Street 2:SUITE 410
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2758
Practice Address - Country:US
Practice Address - Phone:808-261-3000
Practice Address - Fax:808-261-3303
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HI7824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI073127Medicaid
HI073127Medicaid
HI50803Medicare ID - Type Unspecified