Provider Demographics
NPI:1366627143
Name:IWAHARA, MAKOTO (MD)
Entity Type:Individual
Prefix:DR
First Name:MAKOTO
Middle Name:
Last Name:IWAHARA
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 1:120 E 79TH ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0319
Mailing Address - Country:US
Mailing Address - Phone:212-879-2328
Mailing Address - Fax:212-879-1933
Practice Address - Street 1:120 E 79TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0319
Practice Address - Country:US
Practice Address - Phone:212-879-2328
Practice Address - Fax:212-879-1933
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-30
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147656207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB14383Medicare UPIN
NY42D421Medicare PIN