Provider Demographics
NPI:1104967876
Name:FAN, BENNY KP (DO)
Entity type:Individual
Prefix:DR
First Name:BENNY
Middle Name:KP
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:BENNY
Other - Middle Name:KP
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1450 AALA ST
Mailing Address - Street 2:APT#1203
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3604
Mailing Address - Country:US
Mailing Address - Phone:808-537-1416
Mailing Address - Fax:
Practice Address - Street 1:305 ROYAL HAWAIIAN AVE
Practice Address - Street 2:SUITE307
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-2526
Practice Address - Country:US
Practice Address - Phone:808-924-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI23171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist