Provider Demographics
NPI:1861588261
Name:DIEFFENBACH, KEVIN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:DIEFFENBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:98-1247 KAAHUMANU ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5311
Mailing Address - Country:US
Mailing Address - Phone:808-678-1955
Mailing Address - Fax:808-678-1081
Practice Address - Street 1:98-1247 KAAHUMANU ST
Practice Address - Street 2:SUITE 109
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5311
Practice Address - Country:US
Practice Address - Phone:808-678-1955
Practice Address - Fax:808-678-1081
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HI8242208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIF41050Medicare UPIN