Provider Demographics
NPI:1164511309
Name:KOGA, ROY (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:KOGA
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 1:670 PONAHAWAI ST STE 120
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2660
Mailing Address - Country:US
Mailing Address - Phone:808-961-2673
Mailing Address - Fax:808-961-3051
Practice Address - Street 1:670 PONAHAWAI ST STE 120
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2660
Practice Address - Country:US
Practice Address - Phone:808-961-2673
Practice Address - Fax:808-961-3051
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04074-1OtherHMSA BCBS
HI037014-02Medicaid
HI0000BDHSQMedicare ID - Type Unspecified
HIC98501Medicare UPIN