Provider Demographics
NPI:1659615243
Name:MARK, NAOMI T (DPT)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:T
Last Name:MARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S KIHEI ROAD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8145
Mailing Address - Country:US
Mailing Address - Phone:808-874-6972
Mailing Address - Fax:808-874-6973
Practice Address - Street 1:1325 S KIHEI ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8145
Practice Address - Country:US
Practice Address - Phone:808-874-6972
Practice Address - Fax:808-874-6973
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60046225100000X
HIPT4305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01270240OtherRR MEDICARE
OR500651972Medicaid
ORR167829Medicare PIN