Basic Information
Provider Information | |||||||||
NPI: | 1043250723 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIRAMIZU | ||||||||
FirstName: | BRUCE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 677 ALA MOANA BLVD, SUITE 1025 | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968135419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085355975 | ||||||||
FaxNumber: | 8085355976 | ||||||||
Practice Location | |||||||||
Address1: | 3675 KILAUEA AVENUE, 5TH FLOOR | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 96816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8087372751 | ||||||||
FaxNumber: | 8087357047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD10011 | HI | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 087845-02 | 05 | HI |   | MEDICAID |