Provider Demographics
NPI:1588757066
Name:NITTA, RANDALL JIRO (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JIRO
Last Name:NITTA
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 1:98-1247 KAAHUMANU ST STE 306
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5301
Mailing Address - Country:US
Mailing Address - Phone:808-260-4404
Mailing Address - Fax:808-484-2864
Practice Address - Street 1:98-1247 KAAHUMANU ST STE 306
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5301
Practice Address - Country:US
Practice Address - Phone:808-260-4404
Practice Address - Fax:808-484-2864
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD9319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI20867Medicare ID - Type Unspecified
HIG38208Medicare UPIN