Provider Demographics
NPI:1689621674
Name:BOULWARE, DENNIS W (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:BOULWARE
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 1:2828 PAA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4430
Mailing Address - Country:US
Mailing Address - Phone:808-432-5770
Mailing Address - Fax:
Practice Address - Street 1:2828 PAA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4430
Practice Address - Country:US
Practice Address - Phone:808-432-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16747207RR0500X
HIMD-11274207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000084618Medicaid
AL5081OtherHEALTHSPRING
AL660001272OtherRAILROAD MEDICARE
HI0000267930OtherHMSA BILLING NUMBER
AL000084618OtherBLUE CROSS
HI597403-01Medicaid
ALB62186OtherVIVA
AL000084618OtherBLUE CROSS
HIH102763Medicare PIN
B62186Medicare UPIN