Provider Demographics
NPI:1649290545
Name:SHIOTANI, GLENN M (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:SHIOTANI
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 1:55 MAUILANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-243-6050
Mailing Address - Fax:
Practice Address - Street 1:55 MAUILANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-243-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3863170100000X
HIMD-14631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000277376OtherHMSA BILLING NUMBER
HI620361-02Medicaid
HI0000277376OtherHMSA BILLING NUMBER
HIH103828Medicare PIN