Provider Demographics
NPI:1104946763
Name:KAPOLEI PEDIATRICS LLC
Entity type:Organization
Organization Name:KAPOLEI PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:NINOMIYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-693-7300
Mailing Address - Street 1:KAPOLEI BUILDING
Mailing Address - Street 2:1001 KAMOKILA BLVD, SUITE 193
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2014
Mailing Address - Country:US
Mailing Address - Phone:808-693-7300
Mailing Address - Fax:808-693-7301
Practice Address - Street 1:KAPOLEI BUILDING
Practice Address - Street 2:1001 KAMOKILA BLVD, SUITE 193
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2014
Practice Address - Country:US
Practice Address - Phone:808-693-7300
Practice Address - Fax:808-693-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13419208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty