Provider Demographics
NPI:1467758078
Name:KOIDE, KELLY ANN LISA (OD)
Entity Type:Individual
Prefix:MS
First Name:KELLY ANN
Middle Name:LISA
Last Name:KOIDE
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 1:850 W HIND DR
Mailing Address - Street 2:SUITE 212
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1855
Mailing Address - Country:US
Mailing Address - Phone:808-373-4522
Mailing Address - Fax:
Practice Address - Street 1:850 W HIND DR
Practice Address - Street 2:SUITE 212
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1855
Practice Address - Country:US
Practice Address - Phone:808-373-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist