Provider Demographics
NPI:1285649863
Name:IWASKO, NICHOLAS GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GREGORY
Last Name:IWASKO
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 1:4420 CEDARBRUSH DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2901
Mailing Address - Country:US
Mailing Address - Phone:352-222-7431
Mailing Address - Fax:972-542-6915
Practice Address - Street 1:4420 CEDARBRUSH DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-2901
Practice Address - Country:US
Practice Address - Phone:352-222-7431
Practice Address - Fax:972-542-6915
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL33472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI43010774455OtherMEDICAL LICENSE NUMBER
TXL3347OtherMEDICAL LICENSE NUMBER
FLME-0073118OtherMEDICAL LICENSE NUMBER
CAAO68320OtherMEDICAL LICENSE NUMBER
OH35-07-8584-IOtherMEDICAL LICENSE NUMBER
CAAO68320OtherMEDICAL LICENSE NUMBER
TXFTA105Medicare PIN
TXL3347OtherMEDICAL LICENSE NUMBER
FLG90657Medicare UPIN
TX8J3004Medicare PIN
FLME-0073118OtherMEDICAL LICENSE NUMBER