Provider Demographics
NPI:1114006111
Name:KISHIDA, TAKESHI (MD)
Entity Type:Individual
Prefix:
First Name:TAKESHI
Middle Name:
Last Name:KISHIDA
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:PO BOX 11779
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96828-0779
Mailing Address - Country:US
Mailing Address - Phone:808-735-9093
Mailing Address - Fax:
Practice Address - Street 1:2033 NUUANU AVE APT 27B
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2532
Practice Address - Country:US
Practice Address - Phone:808-735-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03346101Medicaid
HI03346101Medicaid
HIH0000BDTRBMedicare ID - Type Unspecified