Provider Demographics
NPI:1790949956
Name:ILLASTRON, DEREK R (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:ILLASTRON
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 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1625
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:
Practice Address - Street 1:110 E KAAHUMANU AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2118
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-243-2367
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235414207R00000X
HIMD-18353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine