Provider Demographics
NPI:1871853796
Name:PETERNELL, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PETERNELL
Suffix:
Gender:M
Credentials:DO
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 1325
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1325
Mailing Address - Country:US
Mailing Address - Phone:808-213-0613
Mailing Address - Fax:
Practice Address - Street 1:81 MAKAWAO AVE STE 204
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8859
Practice Address - Country:US
Practice Address - Phone:808-213-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13464204D00000X, 208D00000X
HIDOS-2186204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIDOS-2186OtherSTATE OF HAWAII