Provider Demographics
NPI:1851371520
Name:IWATA, CHRIS H (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:H
Last Name:IWATA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 501
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0501
Mailing Address - Country:US
Mailing Address - Phone:209-736-0908
Mailing Address - Fax:209-736-9352
Practice Address - Street 1:595 STANISLAUS ST
Practice Address - Street 2:STE C
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222
Practice Address - Country:US
Practice Address - Phone:209-736-0908
Practice Address - Fax:209-736-9352
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5700T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942507411OtherFEDERAL TAX ID
CA0598990001Medicare NSC
CA942507411OtherFEDERAL TAX ID