Provider Demographics
NPI:1588656144
Name:IWAMOTO, CRAIG L (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:L
Last Name:IWAMOTO
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 1:1111 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2314
Mailing Address - Country:US
Mailing Address - Phone:702-383-4040
Mailing Address - Fax:702-383-0526
Practice Address - Street 1:1111 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2314
Practice Address - Country:US
Practice Address - Phone:702-383-4040
Practice Address - Fax:702-383-0526
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVH34747Medicare UPIN
NV34747Medicare ID - Type Unspecified