Provider Demographics
NPI:1598777575
Name:NINOMIYA, JASON TAKEMI (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:TAKEMI
Last Name:NINOMIYA
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 1:1001 KAMOKILA BLVD, SUITE 193
Mailing Address - Street 2:KAPOLEI BUILDING
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2014
Mailing Address - Country:US
Mailing Address - Phone:808-693-7300
Mailing Address - Fax:808-693-7301
Practice Address - Street 1:1001 KAMOKILA BLVD STE 193
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2014
Practice Address - Country:US
Practice Address - Phone:808-693-7300
Practice Address - Fax:808-693-7301
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI568959Medicaid
HI000000Medicare ID - Type UnspecifiedPENDING NEW #
HI568959Medicaid