Provider Demographics
NPI:1588843502
Name:KAILUA DERMATOLOGY CENTERS OF HAWAII, LLC
Entity Type:Organization
Organization Name:KAILUA DERMATOLOGY CENTERS OF HAWAII, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:808-263-3233
Mailing Address - Street 1:1051 KEOLU DR STE 107
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3800
Mailing Address - Country:US
Mailing Address - Phone:808-263-3233
Mailing Address - Fax:808-263-3220
Practice Address - Street 1:1051 KEOLU DR STE 107
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3800
Practice Address - Country:US
Practice Address - Phone:808-263-3233
Practice Address - Fax:808-263-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10836261QM2500X
261QM2500X
HIAMD536363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH103612Medicare PIN