Provider Demographics
NPI:1841566767
Name:IWAMOTO, TRACI ISE (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:ISE
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 1:4228 HOUMA BLVD SUITE 410
Mailing Address - Street 2:
Mailing Address - City:METARIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006
Mailing Address - Country:US
Mailing Address - Phone:504-883-3770
Mailing Address - Fax:504-883-3711
Practice Address - Street 1:1855 4TH ST FL 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2350
Practice Address - Country:US
Practice Address - Phone:415-353-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-25
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303019207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology