Provider Demographics
NPI:1881362739
Name:ISLAND CARDIOVASCULAR & VEIN INSTITUTE LLC
Entity type:Organization
Organization Name:ISLAND CARDIOVASCULAR & VEIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-218-3328
Mailing Address - Street 1:75-5591 PALANI RD STE 2002
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3634
Mailing Address - Country:US
Mailing Address - Phone:210-218-3328
Mailing Address - Fax:
Practice Address - Street 1:75-5591 PALANI RD STE 2002
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3634
Practice Address - Country:US
Practice Address - Phone:210-218-3328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMD-20303OtherHAWAII MEDICAL LICENSE