Provider Demographics
NPI:1295114924
Name:MIYAMOTO, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:MIYAMOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-2618
Mailing Address - Country:US
Mailing Address - Phone:808-428-4940
Mailing Address - Fax:
Practice Address - Street 1:1708 GLEN AVE
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-2618
Practice Address - Country:US
Practice Address - Phone:808-428-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-13727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist