Provider Demographics
NPI:1447256094
Name:OTSUKA, CLIVE I (MD)
Entity type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:I
Last Name:OTSUKA
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 1:321 N KUAKINI ST
Mailing Address - Street 2:STE 811
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2362
Mailing Address - Country:US
Mailing Address - Phone:808-531-2731
Mailing Address - Fax:808-521-2136
Practice Address - Street 1:321 N KUAKINI ST
Practice Address - Street 2:STE 811
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2362
Practice Address - Country:US
Practice Address - Phone:808-531-2731
Practice Address - Fax:808-521-2136
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA01334-0OtherHMSA / BCBS NUMBER
HIC01334-6OtherHMSA / BCBS NUMBER
HI110114260OtherRAILROAD MEDICARE NUMBER
HI01263801Medicaid
HIH0000BDKPJMedicare PIN
HI110114260OtherRAILROAD MEDICARE NUMBER