Provider Demographics
NPI:1245339639
Name:TOLAN, JEFFREY R (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:TOLAN
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 1:67-1185 MAMALAHOA HWY
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-7304
Mailing Address - Country:US
Mailing Address - Phone:808-881-4500
Mailing Address - Fax:
Practice Address - Street 1:67-1185 MAMALAHOA HWY
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7304
Practice Address - Country:US
Practice Address - Phone:808-881-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-13422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI572835-03Medicaid
HI0000254938OtherHMSA BILLING NUMBER
HIH100737Medicare PIN
HID71348Medicare UPIN