Provider Demographics
NPI:1669402236
Name:GERBER, RANDALL GLENN
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:GLENN
Last Name:GERBER
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 1:1474 WAILUKU DR
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 S BERETANIA ST
Practice Address - Street 2:#215
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1520
Practice Address - Country:US
Practice Address - Phone:808-532-3711
Practice Address - Fax:808-532-3713
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7939207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070938-01OtherACS
A002OtherCHAMPUS TRICARE
F69883Medicare UPIN
H50065Medicare ID - Type Unspecified