Provider Demographics
NPI:1174884829
Name:WATAI, TRAVIS (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WATAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PUNCHBOWL ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2499
Mailing Address - Country:US
Mailing Address - Phone:808-691-7657
Mailing Address - Fax:
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813
Practice Address - Country:US
Practice Address - Phone:808-691-7657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2018-07-10
Deactivation Date:2018-06-10
Deactivation Code:
Reactivation Date:2018-06-20
Provider Licenses
StateLicense IDTaxonomies
390200000X
HI18279208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI18279OtherSTATE LICENSE