Provider Demographics
NPI:1346383957
Name:IWASA EYE CENTER P.A.
Entity Type:Organization
Organization Name:IWASA EYE CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETHRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:IWASA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-452-2151
Mailing Address - Street 1:925 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5044
Mailing Address - Country:US
Mailing Address - Phone:208-452-2151
Mailing Address - Fax:208-452-6508
Practice Address - Street 1:925 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-5044
Practice Address - Country:US
Practice Address - Phone:208-642-2151
Practice Address - Fax:208-452-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44270Medicare UPIN
ID1590023Medicare PIN
ID0639500001Medicare NSC