Basic Information
| Provider Information | |||||||||
| NPI: | 1871591362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIRSCH | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 HALAKAU ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968212604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084732144 | ||||||||
| Practice Location | |||||||||
| Address1: | NAVAL HEALTH CLINIC PEARL HARBOR | ||||||||
| Address2: | |||||||||
| City: | PEARL HARBOR | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084732144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G75716 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | G75716 | 01 | CA | MEDICAL LICENSE | OTHER |