Provider Demographics
NPI:1770561938
Name:IWATSUKI, LILLIAN S (MD)
Entity type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:S
Last Name:IWATSUKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2470
Mailing Address - Fax:503-375-7429
Practice Address - Street 1:1165 UNION ST NE
Practice Address - Street 2:SUITE 200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4693
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26846208000000X
OR28745208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500603400Medicaid
G05161Medicare UPIN
OR1228590003Medicare NSC
ORR145782Medicare PIN