Provider Demographics
NPI:1811213523
Name:IIZUKA, KOJI (MD)
Entity type:Individual
Prefix:DR
First Name:KOJI
Middle Name:
Last Name:IIZUKA
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:ATTN: ABS
Mailing Address - Street 2:P.O. BOX 60599
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706
Mailing Address - Country:US
Mailing Address - Phone:808-664-1104
Mailing Address - Fax:866-592-3149
Practice Address - Street 1:PSC 78
Practice Address - Street 2:UNIT 5227
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:315-225-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUEMTL-2020-0232084P0800X
HI165812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry