Provider Demographics
NPI:1396163432
Name:ETTER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ETTER
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 1:151 E WAKEA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2475
Mailing Address - Country:US
Mailing Address - Phone:434-962-3607
Mailing Address - Fax:
Practice Address - Street 1:221 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-244-9056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-05
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI19750207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program