Provider Demographics
NPI:1922550987
Name:AMY REISENAUER MD LLC
Entity Type:Organization
Organization Name:AMY REISENAUER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:KERSTEN
Authorized Official - Last Name:REISENAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-874-3444
Mailing Address - Street 1:1300 N HOLOPONO ST STE 215
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-6945
Mailing Address - Country:US
Mailing Address - Phone:808-874-3444
Mailing Address - Fax:
Practice Address - Street 1:1300 N HOLOPONO ST STE 215
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-6945
Practice Address - Country:US
Practice Address - Phone:808-874-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13436207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty