Provider Demographics
NPI:1144357757
Name:SHIGEZAWA, GLENN (OD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:SHIGEZAWA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 KAPIOLANI BLVD
Mailing Address - Street 2:PH20
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3503
Mailing Address - Country:US
Mailing Address - Phone:808-597-8156
Mailing Address - Fax:808-597-8156
Practice Address - Street 1:1221 KAPIOLANI BLVD
Practice Address - Street 2:PH20
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3503
Practice Address - Country:US
Practice Address - Phone:808-597-8156
Practice Address - Fax:808-597-8156
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02138301Medicaid
HI00000PGBDWMedicare ID - Type Unspecified
HI0467510001Medicare NSC
HI02138301Medicaid