Provider Demographics
NPI:1306184148
Name:BRADLEY KOIZUMI MD INC
Entity Type:Organization
Organization Name:BRADLEY KOIZUMI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOIZUMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-488-6833
Mailing Address - Street 1:99-128 AIEA HEIGHTS DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3925
Mailing Address - Country:US
Mailing Address - Phone:808-488-6833
Mailing Address - Fax:808-591-8880
Practice Address - Street 1:99-128 AIEA HEIGHTS DR
Practice Address - Street 2:SUITE 106
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3925
Practice Address - Country:US
Practice Address - Phone:808-488-6833
Practice Address - Fax:808-591-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI03321207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04029201Medicaid
C98496Medicare UPIN
HI04029201Medicaid