Provider Demographics
NPI:1679646558
Name:OTA, WINSTON Y (MD)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:Y
Last Name:OTA
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:PO BOX 11600
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96828-0600
Mailing Address - Country:US
Mailing Address - Phone:808-735-9093
Mailing Address - Fax:
Practice Address - Street 1:27 NIUHI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1516
Practice Address - Country:US
Practice Address - Phone:808-735-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD9062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI07534901Medicaid
HI0000202465OtherHMSA
HI0000202465OtherHMSA
HIF90296Medicare UPIN