Provider Demographics
NPI:1851303762
Name:SMITH, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
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:96793-1666
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:808-984-7432
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1666
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:808-984-7432
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI010645OtherHMSA, HMSA QUEST, 65CP
HI0348OtherTRICARE CHAMPUS
HI330043OtherUHA
HI0348OtherTRICARE CHAMPUS
HIH100654Medicare PIN
HIQ49834Medicare UPIN