Provider Demographics
NPI:1790382778
Name:OTA, BENJAMIN YSC (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:YSC
Last Name:OTA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45-035 KANEOHE BAY DR
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-2417
Mailing Address - Country:US
Mailing Address - Phone:808-235-5398
Mailing Address - Fax:
Practice Address - Street 1:45-035 KANEOHE BAY DR
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-2417
Practice Address - Country:US
Practice Address - Phone:808-235-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-4926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist