Provider Demographics
NPI:1336240449
Name:OGASAWARA, KEITH K (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:K
Last Name:OGASAWARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3974 OLD PALI RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1009
Mailing Address - Country:US
Mailing Address - Phone:808-284-1343
Mailing Address - Fax:
Practice Address - Street 1:3200 CHANNING WAY STE A102
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7561
Practice Address - Country:US
Practice Address - Phone:208-528-2925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7527207VM0101X
IDM-16831207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI078671-02Medicaid
HI00C0207468OtherHMSA BILLING NUMBER