Healthcare Provider Details

I. General information

NPI: 1386091585
Provider Name (Legal Business Name): KOSUKE KEN IWAKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 E HERNDON AVE
FRESNO CA
93720
US

IV. Provider business mailing address

1303 E HERNDON AVE
FRESNO CA
93720-3309
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-5611
  • Fax: 559-450-7470
Mailing address:
  • Phone: 559-450-5611
  • Fax: 559-450-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA162107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: