Provider Demographics
NPI:1831249515
Name:IWAMI, JEFFREY TAKASHI (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TAKASHI
Last Name:IWAMI
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 1:1436 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2812
Mailing Address - Country:US
Mailing Address - Phone:415-454-0354
Mailing Address - Fax:415-454-0497
Practice Address - Street 1:1436 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2812
Practice Address - Country:US
Practice Address - Phone:415-454-0354
Practice Address - Fax:415-454-0497
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110670Medicare ID - Type Unspecified
CAU95347Medicare UPIN