Provider Demographics
NPI:1437292240
Name:OGATA, THERON (PT)
Entity Type:Individual
Prefix:MR
First Name:THERON
Middle Name:
Last Name:OGATA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5699 KOPIKO ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1668
Mailing Address - Country:US
Mailing Address - Phone:808-329-7744
Mailing Address - Fax:
Practice Address - Street 1:75-5699 KOPIKO ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1668
Practice Address - Country:US
Practice Address - Phone:808-329-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI572265-02Medicaid
HIH55252Medicare PIN