Healthcare Provider Details

I. General information

NPI: 1164511309
Provider Name (Legal Business Name): ROY KOGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PONAHAWAI ST STE 120
HILO HI
96720-2660
US

IV. Provider business mailing address

670 PONAHAWAI ST STE 120
HILO HI
96720-2660
US

V. Phone/Fax

Practice location:
  • Phone: 808-961-2673
  • Fax: 808-961-3051
Mailing address:
  • Phone: 808-961-2673
  • Fax: 808-961-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2816
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: