Provider Demographics
NPI:1154547768
Name:STEPHENSON, KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WILDER AVE APT 2906
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3151
Mailing Address - Country:US
Mailing Address - Phone:808-674-1600
Mailing Address - Fax:
Practice Address - Street 1:2310 KUHIO AVE STE 223
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-2950
Practice Address - Country:US
Practice Address - Phone:808-674-1600
Practice Address - Fax:808-943-1116
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7206208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIE57488Medicare ID - Type Unspecified
HIW79829Medicare UPIN