Healthcare Provider Details

I. General information

NPI: 1417904798
Provider Name (Legal Business Name): IRA M FUJISAKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 KAM HWY 166
PEARL CITY HI
96782-2656
US

IV. Provider business mailing address

850 KAM HWY 166
PEARL CITY HI
96782-2656
US

V. Phone/Fax

Practice location:
  • Phone: 808-455-1922
  • Fax: 808-455-1811
Mailing address:
  • Phone: 808-455-1922
  • Fax: 808-455-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number245
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: