Provider Demographics
NPI:1235123985
Name:IWAHASHI, MARC-ALAN (MD,)
Entity Type:Individual
Prefix:DR
First Name:MARC-ALAN
Middle Name:
Last Name:IWAHASHI
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 1:20555 PROSPECT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-5212
Mailing Address - Country:US
Mailing Address - Phone:408-253-5811
Mailing Address - Fax:408-725-0583
Practice Address - Street 1:20555 PROSPECT RD
Practice Address - Street 2:SUITE A
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-5212
Practice Address - Country:US
Practice Address - Phone:408-253-5811
Practice Address - Fax:408-725-0583
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G685310Medicaid
CA770256595OtherTAX ID NUMBER
CA00G685310Medicaid
CAE78887Medicare UPIN