Healthcare Provider Details

I. General information

NPI: 1336240449
Provider Name (Legal Business Name): KEITH K. OGASAWARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A102
IDAHO FALLS ID
83404-7561
US

IV. Provider business mailing address

3974 OLD PALI RD
HONOLULU HI
96817-1009
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-2925
  • Fax:
Mailing address:
  • Phone: 808-284-1343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD-7527
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberM-16831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: