Provider Demographics
NPI:1376691501
Name:ISHIHARA, JON M (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:M
Last Name:ISHIHARA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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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
HI273152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI03163502Medicaid
HI55923OtherGROUP NUMBER HONOLULU SIT
HI55928OtherGROUP NUMBER WAIPAHU SITE
HI55928OtherGROUP NUMBER WAIPAHU SITE
HIU02043Medicare UPIN
HI03163502Medicaid