Provider Demographics
NPI:1821101148
Name:IWANOFF, JAMES THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THOMAS
Last Name:IWANOFF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:30423 CANWOOD ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2082
Mailing Address - Country:US
Mailing Address - Phone:818-707-2225
Mailing Address - Fax:818-991-9070
Practice Address - Street 1:30423 CANWOOD ST
Practice Address - Street 2:SUITE 225
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2082
Practice Address - Country:US
Practice Address - Phone:818-797-2225
Practice Address - Fax:818-991-9070
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC13558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17522Medicare UPIN