Provider Demographics
NPI:1619915311
Name:O'DONOVAN, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:O'DONOVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1666
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:808-242-4292
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-442-5512
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-11102207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMD-11102OtherHI LIC
HI50606603Medicaid
HIH103181Medicare PIN