Provider Demographics
NPI:1578976270
Name:NYOTOWIDJOJO, IWAN (MD)
Entity Type:Individual
Prefix:
First Name:IWAN
Middle Name:
Last Name:NYOTOWIDJOJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IWAN
Other - Middle Name:
Other - Last Name:NYOTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29472 AVENIDA DE LAS BANDERAS
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688
Mailing Address - Country:US
Mailing Address - Phone:949-459-9968
Mailing Address - Fax:949-766-2565
Practice Address - Street 1:29472 AVENIDA DE LAS BANDERAS
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688
Practice Address - Country:US
Practice Address - Phone:949-459-9968
Practice Address - Fax:949-766-2565
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL45679207R00000X
AZ68913207R00000X
CODR.0069772207R00000X
AZR74508207R00000X
DECL-0025782207R00000X
FLTPME4194207R00000X
IAMD-50889207R00000X
IDMC-1884207R00000X
IN01089040A207R00000X
KSTW-00242207R00000X
KYC1300207R00000X
LA334744207R00000X
MDD0096206207R00000X
MEMD26749207R00000X
CAA90249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR74508OtherARIZONA MEDICAL BOARD TRAINING LICENSE