Provider Demographics
NPI:1285193300
Name:IWAMOTO, SALLY WILLIAMS (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:WILLIAMS
Last Name:IWAMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SALLY
Other - Middle Name:REBECCA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12 EXECUTIVE PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329
Mailing Address - Country:US
Mailing Address - Phone:404-778-7777
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA962572084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology