Provider Demographics
NPI:1023069424
Name:IWAI, RICK T (OD)
Entity type:Individual
Prefix:DR
First Name:RICK
Middle Name:T
Last Name:IWAI
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 1:571 W 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3115
Mailing Address - Country:US
Mailing Address - Phone:310-831-1201
Mailing Address - Fax:310-833-0698
Practice Address - Street 1:571 W 7TH STREET
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3115
Practice Address - Country:US
Practice Address - Phone:310-831-1201
Practice Address - Fax:310-833-0698
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7967TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDOO79670Medicaid
CAU27766Medicare UPIN
CASDOO79670Medicaid
CA0368490001Medicare NSC