1912234196 NPI number — GLORIA M MADAMBA MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912234196 NPI number — GLORIA M MADAMBA MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLORIA M MADAMBA MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1912234196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1712 LILIHA STREET
Provider Second Line Business Mailing Address:
SUITE 203 LILIHA MEDICAL BLG.
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-523-7955
Provider Business Mailing Address Fax Number:
808-536-9498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1712 LILIHA STREET
Provider Second Line Business Practice Location Address:
SUITE 203 LILIHA MEDICAL BLG.
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-523-7955
Provider Business Practice Location Address Fax Number:
808-536-9498
Provider Enumeration Date:
11/10/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MADAMBA
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
M.D.
Authorized Official Telephone Number:
808-523-7955

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2605 , 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: 0354411-01 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".