1598475725 NPI number — BRIAN K ISHIDERA

Table of content: BRIAN K ISHIDERA (NPI 1598475725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598475725 NPI number — BRIAN K ISHIDERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISHIDERA
Provider First Name:
BRIAN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598475725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4348 WAIALAE AVE # 783
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96816-5767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-349-4223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1883 KALAKAUA AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96813-9681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-349-4223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW-4788 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)