Provider Demographics
NPI:1861435430
Name:HADDAD, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:HADDAD
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 1:120 HANA HWY
Mailing Address - Street 2:#9
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-9745
Mailing Address - Country:US
Mailing Address - Phone:808-870-9393
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:96793-2526
Practice Address - Country:US
Practice Address - Phone:808-242-2290
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI8521207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI06989301Medicaid
A48970Medicare UPIN
HI52778Medicare ID - Type Unspecified