Healthcare Provider Details

I. General information

NPI: 1396788527
Provider Name (Legal Business Name): RUSSELL TADASHI OGAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99-128 AIEA HEIGHTS DR SUITE 211
AIEA HI
96701-3925
US

IV. Provider business mailing address

99-128 AIEA HEIGHTS DR SUITE 211
AIEA HI
96701-3925
US

V. Phone/Fax

Practice location:
  • Phone: 808-488-8441
  • Fax: 808-487-2003
Mailing address:
  • Phone: 808-488-8441
  • Fax: 808-487-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10593
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: