Provider Demographics
NPI:1760578355
Name:MIYAMOTO, LEILA M (OD)
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:M
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N KUAKINI ST
Mailing Address - Street 2:STE 605
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-6302
Mailing Address - Country:US
Mailing Address - Phone:808-256-4995
Mailing Address - Fax:808-945-9859
Practice Address - Street 1:750 KEEAUMOKU ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3014
Practice Address - Country:US
Practice Address - Phone:808-256-4995
Practice Address - Fax:808-945-9859
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI990305380 01OtherUNIVERSITY HEALTH ALLIANC
HI01799501Medicaid
HIC0019343OtherHAWAII MEDICAL SERVICE AS
HID0019341OtherHMSA
HI990305380 20OtherUHA
HI990305380 21OtherUHA
HICW997ZOtherPTAN
HI990305380 02OtherUHA
HI990305380 21OtherUHA
HI01799501Medicaid
HI990305380 02OtherUHA
HIH0000PGBMJMedicare ID - Type Unspecified