Provider Demographics
NPI:1477536563
Name:MIYASATO, STEPHEN KEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KEN
Last Name:MIYASATO
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 1:99-128 AIEA HTS DR
Mailing Address - Street 2:STE 105
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3916
Mailing Address - Country:US
Mailing Address - Phone:808-487-9922
Mailing Address - Fax:808-483-6841
Practice Address - Street 1:99-128 AIEA HTS DR
Practice Address - Street 2:STE 105
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3916
Practice Address - Country:US
Practice Address - Phone:808-487-9922
Practice Address - Fax:808-483-6841
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 4730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A001360 5OtherHMSA
192075101OtherHMA
HI990259803Medicaid
0000BDNCWMedicare ID - Type Unspecified
192075101OtherHMA