Provider Demographics
NPI:1275681405
Name:ISHIMOTO, KATHY AK (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:AK
Last Name:ISHIMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-849 LUMIAINA STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797
Mailing Address - Country:US
Mailing Address - Phone:808-671-1656
Mailing Address - Fax:808-671-2020
Practice Address - Street 1:94-849 LUMIAINA STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797
Practice Address - Country:US
Practice Address - Phone:808-671-1656
Practice Address - Fax:808-671-2020
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55928OtherGROUP NUMBER WAIPAHU SITE
HI55923OtherGROUP NUMBER HONOLULU SIT
HI55928OtherGROUP NUMBER WAIPAHU SITE
T41168Medicare UPIN
HI55932Medicare ID - Type UnspecifiedWAIPAHU LOCATION