Basic Information
| Provider Information | |||||||||
| NPI: | 1720042658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATANABE | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 N KUAKINI ST | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968172364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085220190 | ||||||||
| FaxNumber: | 8085239068 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 N KUAKINI ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968172306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085220190 | ||||||||
| FaxNumber: | 8085239068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD3504 | HI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0001215403 | 05 | HI | MEDICAID | 0012773 | 01 | HI | QUEST HMSA | OTHER | 300017130 | 01 | HI | PALMETTO GBA | OTHER | J012771 | 01 | HI | QUEST HMSA | OTHER | 0012773 | 01 | HI | HMSA | OTHER | 0012773 | 01 | HI | BLUE CROSS/BLUE SHIELD | OTHER | 00J0012771 | 01 | HI | QUEST HMSA | OTHER | 99015769896701B006 | 01 | HI | WEST REGION CLAIMS (WPS) | OTHER | 0001215402 | 05 | HI | MEDICAID | 012154-02 | 01 | HI | ST DEPT OF PUB SAFETY | OTHER | 990157698002 | 01 | HI | HAWAII ELECTRICIANS | OTHER | MD3504 | 01 | HI | QUEST-QUEENS HAWAII CARE | OTHER | 012154-03 | 01 | HI | ST DEPT OF PUB SAFETY | OTHER | 20124380 | 01 | HI | US DEPT OF LABOR | OTHER | 990157698-96817-E006 | 01 | HI | TRICARE | OTHER | 1082145098 | 01 | HI | AETNA | OTHER | J012771 | 01 | HI | HMSA | OTHER |