Healthcare Provider Details

I. General information

NPI: 1396931309
Provider Name (Legal Business Name): SHUNPEI KEITH IWATA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 410
PASADENA CA
91105-3154
US

IV. Provider business mailing address

2275 HUNTINGTON DR #861
SAN MARINO CA
91108-2640
US

V. Phone/Fax

Practice location:
  • Phone: 626-535-0900
  • Fax: 626-389-5479
Mailing address:
  • Phone: 626-535-0900
  • Fax: 626-389-5479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA95845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: