Provider Demographics
NPI:1376072850
Name:MUSAEV, TAGAI
Entity type:Individual
Prefix:
First Name:TAGAI
Middle Name:
Last Name:MUSAEV
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 1:1600 KAPIOLANI BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3804
Mailing Address - Country:US
Mailing Address - Phone:808-400-6904
Mailing Address - Fax:808-431-2852
Practice Address - Street 1:1600 KAPIOLANI BLVD STE 508
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3804
Practice Address - Country:US
Practice Address - Phone:808-400-6904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-21663207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology