Provider Demographics
NPI:1952529208
Name:IWAMOTO, GARY K (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:K
Last Name:IWAMOTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1448 15TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2756
Mailing Address - Country:US
Mailing Address - Phone:310-395-3111
Mailing Address - Fax:310-260-1254
Practice Address - Street 1:1448 15TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2756
Practice Address - Country:US
Practice Address - Phone:310-395-3111
Practice Address - Fax:310-260-1254
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0177150Medicare ID - Type Unspecified