Healthcare Provider Details

I. General information

NPI: 1184694192
Provider Name (Legal Business Name): KIYOTAKA ALBERT YAZAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 HALA DR MALUHIA
HONOLULU HI
96817
US

IV. Provider business mailing address

1508B PUALELE PL
HONOLULU HI
96816-3326
US

V. Phone/Fax

Practice location:
  • Phone: 808-832-6129
  • Fax: 808-832-1932
Mailing address:
  • Phone: 808-737-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD-11070
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: