Basic Information
| Provider Information | |||||||||
| NPI: | 1699796730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATEO | ||||||||
| FirstName: | ANNABELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8082432385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8082432385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 208000000X | MD10493 | HI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 9901768599693B011 | 01 | HI | TRICARE CHAMPUS | OTHER | 49740502 | 05 | HI | MEDICAID | 839943 | 01 | HI | UHA | OTHER | 227108 | 01 | HI | HMSA 65CP - HMSA QUEST | OTHER |