Provider Demographics
NPI:1598859142
Name:REDIGER, GLENN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:REDIGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N KING ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4544
Mailing Address - Country:US
Mailing Address - Phone:808-843-7239
Mailing Address - Fax:808-841-1265
Practice Address - Street 1:915 N KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4544
Practice Address - Country:US
Practice Address - Phone:808-843-7239
Practice Address - Fax:808-841-1265
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 4167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0051863101Medicaid
HI0000BDSZQMedicare ID - Type Unspecified
HI0051863101Medicaid