Provider Demographics
NPI:1639240237
Name:IWASAKI, TAKAKO GWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAKAKO
Middle Name:GWEN
Last Name:IWASAKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAKAKO
Other - Middle Name:GWEN
Other - Last Name:IWASAKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4201 TORRANCE BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4504
Mailing Address - Country:US
Mailing Address - Phone:310-540-0079
Mailing Address - Fax:310-316-6871
Practice Address - Street 1:4201 TORRANCE BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4504
Practice Address - Country:US
Practice Address - Phone:310-540-0079
Practice Address - Fax:310-316-6871
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60009207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE 52041Medicare UPIN
CAG60009Medicare PIN