Provider Demographics
NPI:1083651087
Name:WATABE, JOHN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:WATABE
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 1:3288 MOANALUA RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1469
Mailing Address - Country:US
Mailing Address - Phone:808-432-0000
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:808-432-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7267174400000X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No174400000XOther Service ProvidersSpecialist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI087636-01Medicaid
HI0000214064OtherHMSA BILLING NUMBER
HI0000214064OtherHMSA BILLING NUMBER
HI087636-01Medicaid