Provider Demographics
NPI:1134135072
Name:MIMAKI, RONALD (PT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MIMAKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 KALOLINA PL
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2047
Mailing Address - Country:US
Mailing Address - Phone:360-509-0628
Mailing Address - Fax:
Practice Address - Street 1:5722 KALANIANAOLE HWY LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-2388
Practice Address - Country:US
Practice Address - Phone:808-373-3555
Practice Address - Fax:808-373-3666
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007346225100000X
HI5209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB06821Medicare ID - Type Unspecified