Provider Demographics
NPI:1609938398
Name:VAN, ALICIA (OD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 HUKU LII PL
Mailing Address - Street 2:SUITE #107
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7043
Mailing Address - Country:US
Mailing Address - Phone:808-875-4466
Mailing Address - Fax:808-874-3899
Practice Address - Street 1:380 HUKU LII PL
Practice Address - Street 2:SUITE #107
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7043
Practice Address - Country:US
Practice Address - Phone:808-875-4466
Practice Address - Fax:808-874-3899
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD 644152W00000X
TX6767 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBK012ZMedicare PIN