Provider Demographics
NPI:1093897167
Name:IWASAKI, MAKOTO BRANDON (MPT)
Entity Type:Individual
Prefix:MR
First Name:MAKOTO
Middle Name:BRANDON
Last Name:IWASAKI
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-2035
Mailing Address - Country:US
Mailing Address - Phone:951-990-5318
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LN
Practice Address - Street 2:SUITE 204
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3245
Practice Address - Country:US
Practice Address - Phone:703-921-2167
Practice Address - Fax:703-921-1789
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052048022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic