Provider Demographics
NPI:1700970621
Name:SHLACHTER, MARC BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:BRIAN
Last Name:SHLACHTER
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 1:55-510 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:LAIE
Mailing Address - State:HI
Mailing Address - Zip Code:96762-1138
Mailing Address - Country:US
Mailing Address - Phone:808-293-8558
Mailing Address - Fax:808-293-2573
Practice Address - Street 1:55-510 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:LAIE
Practice Address - State:HI
Practice Address - Zip Code:96762-1138
Practice Address - Country:US
Practice Address - Phone:808-293-8558
Practice Address - Fax:808-293-2573
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI034553OtherHMSA NUMBER
HI03110701Medicaid
HI2663OtherDMBA
HI0000034553OtherHMSA QUEST NUMBER
HI034553OtherBLUE
HI990209769OtherTAX ID NUMBER
HIC98626Medicare UPIN
HI03110701Medicaid