Provider Demographics
NPI:1124253810
Name:RAINE FUKUDA UROLOGY, LLC
Entity type:Organization
Organization Name:RAINE FUKUDA UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAINE
Authorized Official - Middle Name:GAY
Authorized Official - Last Name:FUKUDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-521-8288
Mailing Address - Street 1:1712 LILIHA ST.
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3100
Mailing Address - Country:US
Mailing Address - Phone:808-521-8288
Mailing Address - Fax:808-526-0069
Practice Address - Street 1:1712 LILIHA ST.
Practice Address - Street 2:SUITE 302
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3100
Practice Address - Country:US
Practice Address - Phone:808-521-8288
Practice Address - Fax:808-526-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-25
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-15080208800000X
HI15080208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBY425BMedicare UPIN