Basic Information
| Provider Information | |||||||||
| NPI: | 1548316482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AU | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANN | ||||||||
| OtherFirstName: | MELINDA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8089847408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 03/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DOS-1009 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 547416-02 | 05 | HI | MEDICAID |