Provider Demographics
NPI:1942281696
Name:IWAMOTO, MAMI A
Entity Type:Individual
Prefix:
First Name:MAMI
Middle Name:A
Last Name:IWAMOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 STANIFORD ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2517
Mailing Address - Country:US
Mailing Address - Phone:617-367-4800
Mailing Address - Fax:617-723-7028
Practice Address - Street 1:50 STANIFORD ST
Practice Address - Street 2:SUITE 600
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-367-4800
Practice Address - Fax:617-723-7028
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75264207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ12251OtherBCBS MA
MA3093573Medicaid
MA730505OtherTUFTS HEALTH PLAN
E90535Medicare UPIN
MAJ1225101Medicare PIN
MA730505OtherTUFTS HEALTH PLAN