Provider Demographics
NPI:1164633954
Name:KANAYAMA-TRIVEDI, STACY K (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:KANAYAMA-TRIVEDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 CENTRAL AVE
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:JBPHH
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:808-473-1880
Mailing Address - Fax:808-473-4411
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-473-1880
Practice Address - Fax:808-473-4411
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1092479Medicaid
LA1092479Medicaid