Basic Information
| Provider Information | |||||||||
| NPI: | 1619915311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DONOVAN | ||||||||
| FirstName: | ALAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8082424292 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8084425512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD-11102 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD-11102 | HI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | MD-11102 | 01 | HI | HI LIC | OTHER | 50606603 | 05 | HI | MEDICAID |