Provider Demographics
NPI:1730301219
Name:AMBROCIO, DERYLL U (MD)
Entity Type:Individual
Prefix:
First Name:DERYLL
Middle Name:U
Last Name:AMBROCIO
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 804
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2429
Mailing Address - Country:US
Mailing Address - Phone:808-531-7111
Mailing Address - Fax:808-528-5507
Practice Address - Street 1:1329 LUSITANA ST
Practice Address - Street 2:SUITE 804
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2429
Practice Address - Country:US
Practice Address - Phone:808-531-7111
Practice Address - Fax:808-528-5507
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101242738207RR0500X
HIMD-15066207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI635948-01Medicaid
HI00A0285294OtherHMSA BILLING NUMBER
HI635948-01Medicaid