| National Provider Identifier [NPI]: | 1104889583 |
| Last Name Of The Provider | TANTISIRA |
| First Name Of The Provider | JIVIN |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 450 HOOKAHI ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | WAILUKU |
| Zip Code Of The Provider | 967931447 |
| State Code Of The Provider | HI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Ophthalmology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 58 |
| Number Of Services | 19360 |
| Number Of Medicare Beneficiaries | 724 |
| Total Submitted Charge Amount | 1171313.71 |
| Total Medicare Allowed Amount | 684744.21 |
| Total Medicare Payment Amount | 508516.09 |
| Total Medicare Standardized Payment Amount | 491784.56 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 394 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 39692.74 |
| Total Drug Medicare AllowedAmount | 28198.82 |
| Total Drug Medicare PaymentAmount | 22099.51 |
| Total Drug Medicare Standardized Payment Amount | 22099.51 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 54 |
| Number Of Medical Services | 18966 |
| Number Of Medicare Beneficiaries With Medical Services | 724 |
| Total Medical Submitted Charge Amount | 1131620.97 |
| Total Medical Medicare Allowed Amount | 656545.39 |
| Total Medical Medicare Payment Amount | 486416.58 |
| Total Medical Medicare Standardized Payment Amount | 469685.05 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 35 |
| Number Of Beneficiaries Age 65 to 74 | 311 |
| Number Of Beneficiaries Age 75 to 84 | 270 |
| Number Of Beneficiaries Age Greater 84 | 108 |
| Number Of Female Beneficiaries | 398 |
| Number Of Male Beneficiaries | 326 |
| Number Of Non Hispanic White Beneficiaries | 337 |
| Number Of Black or African American Beneficiaries | 0 |
| Number Of AsianPacific Islander Beneficiaries | 285 |
| Number Of Hispanic Beneficiaries | 48 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 54 |
| Number Of Beneficiaries With Medicare Only Entitlement | 648 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 76 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 34 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.0365 |