Provider Demographics
NPI:1538280367
Name:SHIMOMURA, GREGG ATSUSHI (MD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:ATSUSHI
Last Name:SHIMOMURA
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 HEIGHTS DRIVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3938
Mailing Address - Country:US
Mailing Address - Phone:808-487-2497
Mailing Address - Fax:808-487-2494
Practice Address - Street 1:99 128 AIEA HEIGHTS DRIVE
Practice Address - Street 2:SUITE 504
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3938
Practice Address - Country:US
Practice Address - Phone:808-487-2497
Practice Address - Fax:808-487-2494
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD6215207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05906901Medicaid
HI078493OtherHAWAII MEDICAL SERVICE AS
E58532Medicare UPIN
0000BDRJQMedicare ID - Type Unspecified