Basic Information
| Provider Information | |||||||||
| NPI: | 1609221886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTELLY | ||||||||
| FirstName: | MEGHANN | ||||||||
| MiddleName: | LAU | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAU | ||||||||
| OtherFirstName: | MEGHANN | ||||||||
| OtherMiddleName: | WENWAI | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 86-260 FARRINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086973300 | ||||||||
| FaxNumber: | 8086973930 | ||||||||
| Practice Location | |||||||||
| Address1: | 86-260 FARRINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086973300 | ||||||||
| FaxNumber: | 8086973930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-20453 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 420745064 | 01 | HI | US PASSPORT | OTHER |