Provider Demographics
NPI:1669564050
Name:TAKAZAWA, LYDIA W (MD)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:W
Last Name:TAKAZAWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1010 PENSACOLA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2118
Mailing Address - Country:US
Mailing Address - Phone:808-432-2000
Mailing Address - Fax:
Practice Address - Street 1:1010 PENSACOLA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2118
Practice Address - Country:US
Practice Address - Phone:808-432-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI057243-01Medicaid
HI0000065920OtherHMSA BILLING NUMBER
HIF70880Medicare UPIN
HI057243-01Medicaid