Provider Demographics
NPI:1730252685
Name:KOIZUMI, BRADLEY H (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:H
Last Name:KOIZUMI
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 1:1040 S KING ST
Mailing Address - Street 2:SUITE 312
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2117
Mailing Address - Country:US
Mailing Address - Phone:808-591-8880
Mailing Address - Fax:
Practice Address - Street 1:1040 S KING ST
Practice Address - Street 2:SUITE 312
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2117
Practice Address - Country:US
Practice Address - Phone:808-591-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2010-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04029201Medicaid
HI004433-9OtherHMSA
0000BDGBVMedicare ID - Type Unspecified
HI04029201Medicaid