Provider Demographics
NPI:1922177351
Name:IWATA, JAN LEI (DO)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:LEI
Last Name:IWATA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4600 N CLARENDON AVE
Mailing Address - Street 2:1202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5710
Mailing Address - Country:US
Mailing Address - Phone:773-501-7394
Mailing Address - Fax:
Practice Address - Street 1:1 E SUPERIOR ST
Practice Address - Street 2:307
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2507
Practice Address - Country:US
Practice Address - Phone:773-501-7394
Practice Address - Fax:773-296-7787
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7541204D00000X, 207W00000X, 2083P0901X
IL036-105234207W00000X, 204D00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632904OtherBLUE CROSS BLUE SHIELD