Healthcare Provider Details

I. General information

NPI: 1588845895
Provider Name (Legal Business Name): MARTHA IWAMOTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YUKON-KUSKOKWIM HEALTH CORPORATION YUKON-KUSKOKWIM DELTA REGIONAL HOSPITAL
BETHEL AK
99559
US

IV. Provider business mailing address

201 W PONCE DE LEON AVE UNIT 318
DECATUR GA
30030-3261
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-0000
  • Fax:
Mailing address:
  • Phone: 404-639-4745
  • Fax: 404-639-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47454
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: