Provider Demographics
NPI:1386851905
Name:IWATA, NELSON TOSHIO (OD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:TOSHIO
Last Name:IWATA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 PLAZA DEL AMO
Mailing Address - Street 2:UNIT 214
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7388
Mailing Address - Country:US
Mailing Address - Phone:808-722-4112
Mailing Address - Fax:
Practice Address - Street 1:3800 ROSEDALE HWY
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-6235
Practice Address - Country:US
Practice Address - Phone:661-861-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI206152W00000X
CA7968152W00000X
CA7968TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH52893Medicare ID - Type Unspecified