Provider Demographics
NPI:1457449944
Name:KIDA, DERRICK TAMOTSU (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:TAMOTSU
Last Name:KIDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N. KUAKINI ST.
Mailing Address - Street 2:SUITE #201
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2399
Mailing Address - Country:US
Mailing Address - Phone:808-523-8611
Mailing Address - Fax:
Practice Address - Street 1:321 N. KUAKINI ST.
Practice Address - Street 2:SUITE #201
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2399
Practice Address - Country:US
Practice Address - Phone:808-523-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7657208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04159001Medicaid
F57331Medicare UPIN
BFBCCMedicare ID - Type Unspecified