Provider Demographics
NPI:1588845895
Name:IWAMOTO, MARTHA (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:IWAMOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W PONCE DE LEON AVE UNIT 318
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3261
Mailing Address - Country:US
Mailing Address - Phone:404-639-4745
Mailing Address - Fax:404-639-2205
Practice Address - Street 1:YUKON-KUSKOKWIM HEALTH CORPORATION
Practice Address - Street 2:YUKON-KUSKOKWIM DELTA REGIONAL HOSPITAL
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics