1164457511 NPI number — DR. WENDELL K. S. FOO M.D.

Table of content: DR. WENDELL K. S. FOO M.D. (NPI 1164457511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164457511 NPI number — DR. WENDELL K. S. FOO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOO
Provider First Name:
WENDELL
Provider Middle Name:
K. S.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164457511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4348 WAIALAE AVE 5-311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96816-5767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-373-4007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 KILANI AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAHIAWA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96786-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-621-8448
Provider Business Practice Location Address Fax Number:
808-621-2082
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  MD-4923 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 025354-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191559/01 . This is a "HMA/SUMMERLIN PROV. #" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: H0000BDNKQ . This is a "MEDICARE ID" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 2821-7 . This is a "HMSA PROV. # - HI" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 2821-7 . This is a "BLUE CROSS/SHIELD PROV. #" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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