1619078615 NPI number — DR. WALLACE J MATTHEWS JR. M.D.

Table of content: DR. WALLACE J MATTHEWS JR. M.D. (NPI 1619078615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619078615 NPI number — DR. WALLACE J MATTHEWS JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS
Provider First Name:
WALLACE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1619078615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 S KING ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96814-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-593-9944
Provider Business Mailing Address Fax Number:
808-593-0565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 S KING ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-593-9944
Provider Business Practice Location Address Fax Number:
808-593-0565
Provider Enumeration Date:
09/25/2006

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: 208000000X , with the licence number:  MD4255 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2080P0214X , with the licence number: MD4255 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 00519101 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD4255-01 . This is a "QHCP" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 0000004481 . This is a "QHMS" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 00519101 . This is a "QALC" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 192509 . This is a "HMAI" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 04481 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: J4489 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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