Provider Demographics
NPI:1881631422
Name:ICHIYAMA-KONG, COLLEEN MARIKO (OD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARIKO
Last Name:ICHIYAMA-KONG
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 1:2049 WELLS ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2239
Mailing Address - Country:US
Mailing Address - Phone:808-244-8034
Mailing Address - Fax:808-244-8035
Practice Address - Street 1:2049 WELLS ST
Practice Address - Street 2:SUITE #1
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2239
Practice Address - Country:US
Practice Address - Phone:808-244-8034
Practice Address - Fax:808-244-8035
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI50181802Medicaid
HI50181802Medicaid
HIU90889Medicare UPIN