Provider Demographics
NPI:1184994147
Name:STEVEN G IWASA OD PLLC
Entity type:Organization
Organization Name:STEVEN G IWASA OD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:IWASA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-414-1600
Mailing Address - Street 1:36 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1941
Mailing Address - Country:US
Mailing Address - Phone:208-414-1600
Mailing Address - Fax:208-414-1607
Practice Address - Street 1:36 W COURT ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1941
Practice Address - Country:US
Practice Address - Phone:208-414-1600
Practice Address - Fax:208-414-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODD649152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0008449Medicaid
814368000OtherBLUE CROSS / BLUE SHIELD
P00102776OtherRR MEDICARE
V4999OtherBLUE CROSS
000010137310OtherBLUE SHIELD
V4999OtherBLUE CROSS