Provider Demographics
NPI:1811199417
Name:MISTR, SUSANNAH KERR (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:KERR
Last Name:MISTR
Suffix:
Gender:F
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:PO BOX 383147
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-3147
Mailing Address - Country:US
Mailing Address - Phone:808-883-3767
Mailing Address - Fax:
Practice Address - Street 1:68-1845 WAIKOLOA RD
Practice Address - Street 2:SUITE 218
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738-5584
Practice Address - Country:US
Practice Address - Phone:808-883-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 15669207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIP00926555OtherRR MEDICARE
HI645070Medicaid
HIP00926555OtherRR MEDICARE