Provider Demographics
NPI:1689720880
Name:WATANABE, GLENN MIKIO (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MIKIO
Last Name:WATANABE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-239 WAIPAHU DEPOT ST
Mailing Address - Street 2:#213
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3056
Mailing Address - Country:US
Mailing Address - Phone:808-671-2888
Mailing Address - Fax:808-676-1097
Practice Address - Street 1:94-239 WAIPAHU DEPOT ST
Practice Address - Street 2:#213
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3056
Practice Address - Country:US
Practice Address - Phone:808-671-2888
Practice Address - Fax:808-676-1097
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-151152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04677102Medicaid
HIT41307Medicare UPIN
HI0754700001Medicare NSC
HIOOOOPGBBTMedicare ID - Type Unspecified