Provider Demographics
NPI:1114123098
Name:TAMAMOTO, BRENT KOICHI (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:KOICHI
Last Name:TAMAMOTO
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 1:99-080 KAUHALE ST
Mailing Address - Street 2:SUITE C-22
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4114
Mailing Address - Country:US
Mailing Address - Phone:808-487-1600
Mailing Address - Fax:808-487-1601
Practice Address - Street 1:99-080 KAUHALE ST
Practice Address - Street 2:SUITE C-22
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4114
Practice Address - Country:US
Practice Address - Phone:808-487-1600
Practice Address - Fax:808-487-1601
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 14517208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI618043Medicaid