Provider Demographics
NPI:1346529153
Name:TSUBATA, KEN DAIJI (DPM)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:DAIJI
Last Name:TSUBATA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 ULUNIU ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2519
Mailing Address - Country:US
Mailing Address - Phone:808-266-0066
Mailing Address - Fax:808-263-6004
Practice Address - Street 1:407 ULUNIU ST
Practice Address - Street 2:SUITE 107
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2519
Practice Address - Country:US
Practice Address - Phone:808-266-0066
Practice Address - Fax:808-263-6004
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPO 212213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH105182Medicare PIN