Healthcare Provider Details

I. General information

NPI: 1649256793
Provider Name (Legal Business Name): KEN HAYATO UYESUGI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 482 BOX 2774
FPO AP
96362
JP

IV. Provider business mailing address

PSC 482 BOX 2774
FPO AP
96362
JP

V. Phone/Fax

Practice location:
  • Phone: 011816117437797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number408
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: