Provider Demographics
NPI:1417040700
Name:MAKOTO IWAHARA, MD, PC
Entity Type:Organization
Organization Name:MAKOTO IWAHARA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAKOTO
Authorized Official - Middle Name:
Authorized Official - Last Name:IWAHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-879-2328
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZTZR1Medicare PIN
B14383Medicare UPIN