Provider Demographics
NPI:1598834632
Name:ANDREW G. IWACH MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ANDREW G. IWACH MD A PROFESSIONAL CORPORATION
Other - Org Name:GLAUCOMA ASSOCIATES OF NORTHERN CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:IWACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-989-2020
Mailing Address - Street 1:55 STEVENSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-2936
Mailing Address - Country:US
Mailing Address - Phone:415-981-2020
Mailing Address - Fax:415-981-2019
Practice Address - Street 1:55 STEVENSON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-2936
Practice Address - Country:US
Practice Address - Phone:415-981-2020
Practice Address - Fax:415-981-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56142207W00000X
CA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G561420Medicaid
CAI60984Medicare UPIN
CAG86414Medicare UPIN
CAZZZ13185ZMedicare PIN
CAG77949Medicare UPIN
CAZZZ13185ZMedicare UPIN
CA00G561420Medicaid
CAE88882Medicare UPIN