Provider Demographics
NPI:1245336445
Name:KOJIMA, WALLACE M (OD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:M
Last Name:KOJIMA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:73-5600 MAIAU ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2630
Mailing Address - Country:US
Mailing Address - Phone:808-331-8081
Mailing Address - Fax:808-331-8082
Practice Address - Street 1:73-5600 MAIAU ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2630
Practice Address - Country:US
Practice Address - Phone:808-331-8081
Practice Address - Fax:808-331-8082
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIT41183Medicare UPIN