Provider Demographics
NPI:1669654141
Name:WOOLLEY, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WOOLLEY
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 1:1329 LUSITANA ST
Mailing Address - Street 2:SUITE 604
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2429
Mailing Address - Country:US
Mailing Address - Phone:808-531-1116
Mailing Address - Fax:808-524-7911
Practice Address - Street 1:1329 LUSITANA ST
Practice Address - Street 2:SUITE 604
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2429
Practice Address - Country:US
Practice Address - Phone:808-531-1116
Practice Address - Fax:808-524-7911
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-03378207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04564901Medicaid
HI04564901Medicaid
HIH0000BDHFTMedicare PIN