Provider Demographics
NPI:1346263670
Name:IWAOKA, KEN RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:RAY
Last Name:IWAOKA
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 1:10170 SORRENTO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1604
Mailing Address - Country:US
Mailing Address - Phone:858-784-5888
Mailing Address - Fax:
Practice Address - Street 1:130 CEDAR RD
Practice Address - Street 2:# 100
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5102
Practice Address - Country:US
Practice Address - Phone:760-806-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A486300Medicaid
CAAY044Medicare PIN
CAE69473Medicare UPIN
CA00A486300Medicaid