Provider Demographics
NPI:1043573017
Name:IWANO, MIKA (MD)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:
Last Name:IWANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIKA
Other - Middle Name:
Other - Last Name:ITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4973
Mailing Address - Country:US
Mailing Address - Phone:602-344-5461
Mailing Address - Fax:602-344-5805
Practice Address - Street 1:1001 MAIN ST FL 5
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ57098207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program