Provider Demographics
NPI:1871781153
Name:GANDIA, DERELYNE KUULANI ROSE (OD)
Entity type:Individual
Prefix:
First Name:DERELYNE
Middle Name:KUULANI ROSE
Last Name:GANDIA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 KUKUI GROVE ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766
Mailing Address - Country:US
Mailing Address - Phone:808-212-6235
Mailing Address - Fax:808-632-2020
Practice Address - Street 1:4414 KUKUI GROVE ST.
Practice Address - Street 2:STE. 101
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766
Practice Address - Country:US
Practice Address - Phone:808-632-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13180T152W00000X
HIOD674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI61300102Medicaid
HI61300102Medicaid