Provider Demographics
NPI:1700869427
Name:JOHNSON, DOUGLAS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:JOHNSON
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 1:1380 LUSITANA ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2449
Mailing Address - Country:US
Mailing Address - Phone:808-531-7541
Mailing Address - Fax:808-531-7542
Practice Address - Street 1:1380 LUSITANA ST
Practice Address - Street 2:SUITE 401
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2449
Practice Address - Country:US
Practice Address - Phone:808-531-7541
Practice Address - Fax:808-531-7542
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3122174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03988501Medicaid
HIC43801-6OtherHMSA
HIC43801-6OtherHMSA