Provider Demographics
NPI:1619078615
Name:MATTHEWS, WALLACE J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
Last Name:MATTHEWS
Suffix:JR
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 1:1350 S KING ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2009
Mailing Address - Country:US
Mailing Address - Phone:808-593-9944
Mailing Address - Fax:808-593-0565
Practice Address - Street 1:1350 S KING ST
Practice Address - Street 2:SUITE 300
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2009
Practice Address - Country:US
Practice Address - Phone:808-593-9944
Practice Address - Fax:808-593-0565
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4255208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00519101Medicaid
HIMD4255-01OtherQHCP
HI0000004481OtherQHMS
HI00519101OtherQALC
HI192509OtherHMAI
HI04481OtherHMSA
HIJ4489OtherHMSA
HI00519101Medicaid
HI0000004481OtherQHMS