Provider Demographics
NPI:1437264348
Name:YAMAMOTO-KUBO, TRACEY (OD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:YAMAMOTO-KUBO
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 1:915 N KING ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4544
Mailing Address - Country:US
Mailing Address - Phone:808-845-0686
Mailing Address - Fax:808-845-0798
Practice Address - Street 1:915 N KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4544
Practice Address - Country:US
Practice Address - Phone:808-845-0686
Practice Address - Fax:808-845-0798
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000213074OtherBLUE CROSS BLUE SHIELD
HI0051863109Medicaid
H4455250001Medicare ID - Type Unspecified
HI0000213074OtherBLUE CROSS BLUE SHIELD