Provider Demographics
NPI:1720042658
Name:WATANABE, TED J (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:J
Last Name:WATANABE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:321 N KUAKINI ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2364
Mailing Address - Country:US
Mailing Address - Phone:808-522-0190
Mailing Address - Fax:808-523-9068
Practice Address - Street 1:347 N KUAKINI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2306
Practice Address - Country:US
Practice Address - Phone:808-522-0190
Practice Address - Fax:808-523-9068
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HIMD35042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0001215403Medicaid
HI0012773OtherQUEST HMSA
HI300017130OtherPALMETTO GBA
HIJ012771OtherQUEST HMSA
HI0012773OtherHMSA
HI0012773OtherBLUE CROSS/BLUE SHIELD
HI00J0012771OtherQUEST HMSA
HI99015769896701B006OtherWEST REGION CLAIMS (WPS)
HI0001215402Medicaid
HI012154-02OtherST DEPT OF PUB SAFETY
HI990157698002OtherHAWAII ELECTRICIANS
HIMD3504OtherQUEST-QUEENS HAWAII CARE
HI012154-03OtherST DEPT OF PUB SAFETY
HI20124380OtherUS DEPT OF LABOR
HI990157698-96817-E006OtherTRICARE
HI1082145098OtherAETNA
HIJ012771OtherHMSA
HI0001215402Medicaid
HI0001215403Medicaid