Provider Demographics
NPI:1942325634
Name:IAN KAWAMOTO, OD LLC
Entity Type:Organization
Organization Name:IAN KAWAMOTO, OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAWAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-252-7310
Mailing Address - Street 1:4825 S RAINBOW BLVD
Mailing Address - Street 2:STE. 203
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4914
Mailing Address - Country:US
Mailing Address - Phone:702-252-7310
Mailing Address - Fax:702-252-7320
Practice Address - Street 1:4825 S RAINBOW BLVD
Practice Address - Street 2:STE. 203
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4914
Practice Address - Country:US
Practice Address - Phone:702-252-7310
Practice Address - Fax:702-252-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100002Medicare ID - Type Unspecified
NVV02427Medicare UPIN