Provider Demographics
NPI:1841222106
Name:ITO, JENNIFER S (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:ITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 LILIHA ST STE 306
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1605
Mailing Address - Country:US
Mailing Address - Phone:808-531-5711
Mailing Address - Fax:808-531-5722
Practice Address - Street 1:2226 LILIHA ST STE 306
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1605
Practice Address - Country:US
Practice Address - Phone:808-531-5711
Practice Address - Fax:808-531-5722
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 11442174400000X
HI11442207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIQHCOtherQUEEN'S HEALTH CARE
HI99-0355462OtherHMAA
HI023006OtherHMSA
HI50109001Medicaid
HI880233182OtherRAILROAD MEDICARE
HIH53478Medicare ID - Type UnspecifiedMEDICARE
HIH37983Medicare UPIN